Exhibit III - Medication Log.pdf

PDF 127 KB Posted Jun 1, 2024

Attached to: Master Agreement AZ|CTR071439
Contract number: CTR071439
Issued by: Arizona

About this file

Written by GovTribe AI · Sep 19, 2025

This document is a Congregate Care Medication Log form created by the Arizona Department of Child Safety, dated 05/24. The form is an administrative tracking tool designed for documenting medication administration for clients in congregate care settings, specifically for children under the care of the state's child safety department.

The form provides a comprehensive template for recording detailed medication information, including patient details, prescription specifics, dosage times, and a log for tracking medication administration. It includes fields for tracking missed doses with specific reason codes (such as Refused, AWOL, School, Discontinued), daily medication counts, medications sent on or returned from passes, and requires both client and staff initials. The form also includes sections for medication evaluation, refill tracking, and management verification, ensuring systematic and accountable medication management for clients in congregate care.

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CONGREGATE CARE

MEDICATION LOG

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit III (05/24)

Missed Dose Reason Code R Refused A AWOL S School D Discontinued M Missed H Hospital P On Pass

Client’s Name Date of Birth

Date to Order Refill

CHP Phone No.

Refill Start Date

CHP Email

Refill Bottle Count

Pharmacy Location Pharmacy Phone No.

Month

Refill Available

Travel BottlePhysician’s Name Physician’s Emergency Phone No.

Year

Medication Date of Prescription

Date of Placement

Prescribed Dosage Times of Dosage:

Purpose of Medication

Prescribed Instructions:

DateDate TimeTime DoseDose Comments Comments Daily MedDaily Med CountCount

No. Meds No. Meds Sent on Pass Sent on Pass

No. Meds Returned No. Meds Returned from Passfrom Pass

Client Client InitialInitial

Staff Initial & Staff Initial & Last NameLast Name

Yes

CONGREGATE CARE

MEDICATION LOG

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit III (05/24)

Month Year

DateDate TimeTime DoseDose Comments Comments Daily MedDaily Med CountCount

No. Meds No. Meds Sent on Pass Sent on Pass

No. Meds Returned No. Meds Returned from Passfrom Pass

Client Client InitialInitial

Staff Initial & Staff Initial & Last NameLast Name as of Date Last Med Evaluation Checked by ManagementRefill Available Travel Bottle

Date to Order Refill Next Med Evaluation Refill Bottle Count (prior to starting the bottle) Refill Started Date (only to be filled out when a refill bottle starts)

Med Count Yes No Yes No

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File details come from the government source that posted it. Updated Sep 19, 2025.