Cobb County School District

Form JGCD-15 Empowering Dreams for the Future

CONTROLLED SUBSTANCES INVENTORY FORM

School:

     

Student’s Name:

     

Medication:

     

Dose:

     

Column A

Column B

Column C

Column D

Column E

Column F

DATE

TIME

NUMBER OF PILLS AT

LAST COUNT

(Last Entry In Column F)

NUMBER OF PILLS RECEIVED

FORM JGCD-4 (Controlled Substances: Quantity Received)

TOTAL

(Column A+B)

NUMBER GIVEN/USED

FORM JGCD-3

(Medication Administration Record)

NUMBER

WASTED

ENTER CODE:

D-Dropped On Floor

V-Student Vomited

Medication

TOTAL NUMBER

PILLS REMAINING IN BOTTLE

(Enter Here and in

Column A)

SCHOOL NURSE

SIGNATURE

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

7/1/08: School Health Services *JGCD-15* Page 1 of 1