DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 1199 (Rev. 12/04)
STATE OF WISCONSIN
OPTIONAL SCHOOL-BASED SERVICES ACTIVITY LOG MEDICATION ADMINISTRATION
Name -- Student (Last, First, MI) Name -- School Took Medication Without Difficulty? (Yes or No) Method Used (Circle One) Time Date of Service (MM/DD/YY) Time Administered (Time or Units) Notes (All Exceptions Must Be Noted) Task Initials or Signature* (Of Person Who Administered Medication)
Medication Name and Dose
Signatures -- Corresponding Staff
Date Signed (MM/DD/YY)
Under Standards of Practice for Registered Nurses, ch. N 6.03, Wis. Admin. Code, only registered nurses (RNs) may delegate services to medically unlicensed individuals. For delegated nursing services under the school-based services benefit, the RN responsible for delegating the services must agree to the delegation of the service and is responsible for supervision of the delegatee.