ࡱ> y 1bjbj .{{1 z:$f4  A J0z,z :  SACRAMENTO CITY UNIFIED SCHOOL DISTRICT Community, Health and Education Support Services Division Health Services Office MEDICATION RECORD (Record of Pupil's Medication Administered by School Personnel) STUDENT: ____________________________________ SCHOOL YEAR: ________ TEACHER/RM: ____________________/_____ BIRTHDATE: _____________________ PARENTS' NAME: ___________________________________ PHONE: ________________ PHYSICIAN: _________________________________________________________________________PHONE: ________________ MEDICATION: ________________________ RX NO. _______________ DOSAGE/FORM: _________ SCHEDULE: _____________ DATE STARTED: ___________________________ DATE OF DISCONTINUANCE: _______________________________________ RESTRICTIONS/CAUTIONS: ___________________________________________________________________________________ MEDICATION MAY BE ADMINISTERED ONLY BY PERSONNEL DESIGNATED BY THE PRINCIPAL/ADMINISTRATOR. 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