Loammi Campbell Guanfacine HCL ER 1 MG (PM)

ARIZONA DEPARTMENT OF CHILD SAFETY
CONGREGATE CARE MEDICATION LOG
AM / NOON / PM
Date of Placement

MonthDayYear
Date
Month
Year
Clients Name
Date of Birth

MonthDayYear
Date
Medication
Date of Prescription

MonthDayYear
Date
Physicians Name
Physician's Emergency Phone No.
Format: (000) 000-0000.
Prescribed Dosage
Times of Dosage
CHP Phone No.
Format: (000) 000-0000.
CHP Email
example@example.com
Pharmacy Location
Pharmacy Phone No.
Format: (000) 000-0000.
Purpose of Medication
Prescribed Instructions
Date to Order Refill

MonthDayYear
Date
Refill Start Date

MonthDayYear
Date
Refill Bottle Count
Missed Dose Reason Code RRefusedAAWOL
Discontinued
Dosage
YESNO
Client No. Meds No. Meds Returned Sent on Passfrom PassInitial
Day 1 Time

Hour Minutes

AM/PM Option
Day 1: Youth Initials

Clear
Day 1: Staff Initials & Last Name

Clear
Day 1: Daily Med Count
Day 1 Comments
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 2: Time

Hour Minutes

AM/PM Option
Day 2: Youth Initials

Clear
Day 2: Staff Initials & Last Name

Clear
Day 2 Comments
Day 2: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 3: Time

Hour Minutes

AM/PM Option
Day 3: Staff Initials & Last Name

Clear
Day 3: Youth Initials

Clear
Day 3 Comments
Day 3: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 4: Time

Hour Minutes

AM/PM Option
Day 4: Staff Initials & Last Name

Clear
Day 4: Youth Initials

Clear
Day 4 Comments
Day 4: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 5: Time

Hour Minutes

AM/PM Option
Day 5: Staff Initials & Last Name

Clear
Day 5: Youth Initials

Clear
Day 5 Comments
Day 5: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 6: Time

Hour Minutes

AM/PM Option
Day 6: Staff Initials & Last Name

Clear
Day 6: Youth Initials

Clear
Day 6 Comments
Day 6: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 7: Time

Hour Minutes

AM/PM Option
Day 7: Staff Initials & Last Name

Clear
Day 7: Youth Initials

Clear
Day 7 Comments
Day 7: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 8: Time

Hour Minutes

AM/PM Option
Day 8: Staff Initials & Last Name

Clear
Day 8: Youth Initials

Clear
Day 8 Comments
Day 8: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 9: Time

Hour Minutes

AM/PM Option
Day 9: Staff Initials & Last Name

Clear
Day 9: Youth Initials

Clear
Day 9 Comments
Day 9: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 10: Time

Hour Minutes

AM/PM Option
Day 10: Staff Initials & Last Name

Clear
Day 10: Youth Initials

Clear
Day 10 Comments
Day 10: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 11: Time

Hour Minutes

AM/PM Option
Day 11: Staff Initials & Last Name

Clear
Day 11: Youth Initials

Clear
Day 11 Comments
Day 11: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 12: Time

Hour Minutes

AM/PM Option
Day 12: Staff Initials & Last Name

Clear
Day 12: Youth Initials

Clear
Day 12 Comments
Day 12: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 13: Time

Hour Minutes

AM/PM Option
Day 13: Staff Initials & Last Name

Clear
Day 13: Youth Initials

Clear
Day 13 Comments
Day 13: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 14: Time

Hour Minutes

AM/PM Option
Day 14: Staff Initials & Last Name

Clear
Day 14: Youth Initials

Clear
Day 14 Comments
Day 14: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 15: Time

Hour Minutes

AM/PM Option
Day 15: Staff Initials & Last Name

Clear
Day 15: Youth Initials

Clear
Day 15 Comments
Day 15: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 16: Time

Hour Minutes

AM/PM Option
Day 16: Staff Initials & Last Name

Clear
Day 16: Youth Initials

Clear
Day 16 Comments
Day 16: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 17: Time

Hour Minutes

AM/PM Option
Day 17: Staff Initials & Last Name

Clear
Day 17: Youth Initials

Clear
Day 17 Comments
Day 17: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 18: Time

Hour Minutes

AM/PM Option
Day 18: Staff Initials & Last Name

Clear
Day 18 Comments
Day 18: Daily Med Count
Day 18: Youth Initials

Clear
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 19: Time

Hour Minutes

AM/PM Option
Day 19: Staff Initials & Last Name

Clear
Day 19: Youth Initials

Clear
Day 19 Comments
Day 19: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 20: Time

Hour Minutes

AM/PM Option
Day 20: Staff Initials & Last Name

Clear
Day 20: Youth Initials

Clear
Day 20 Comments
Day 20: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 21: Time

Hour Minutes

AM/PM Option
Day 21: Staff Initials & Last Name

Clear
Day 21: Youth Initials

Clear
Day 21 Comments
Day 21: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 22: Time

Hour Minutes

AM/PM Option
Day 22: Staff Initials & Last Name

Clear
Day 22: Youth Initials

Clear
Day 22 Comments
Day 22: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 23: Time

Hour Minutes

AM/PM Option
Day 23: Staff Initials & Last Name

Clear
Day 23: Youth Initials

Clear
Day 23 Comments
Day 23: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 24: Time

Hour Minutes

AM/PM Option
Day 24: Staff Initials & Last Name

Clear
Day 24: Youth Initials

Clear
Day 24 Comments
Day 24: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 25: Time

Hour Minutes

AM/PM Option
Day 25: Staff Initials & Last Name

Clear
Day 25: Youth Initials

Clear
Day 25 Comments
Day 25: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 26: Time

Hour Minutes

AM/PM Option
Day 26: Staff Initials & Last Name

Clear
Day 26: Youth Initials

Clear
Day 26 Comments
Day 26: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 27: Time

Hour Minutes

AM/PM Option
Day 27: Staff Initials & Last Name

Clear
Day 27: Youth Initials

Clear
Day 27 Comments
Day 27: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 28: Time

Hour Minutes

AM/PM Option
Day 28: Staff Initials & Last Name

Clear
Day 28: Youth Initials

Clear
Day 28 Comments
Day 28: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 29: Time

Hour Minutes

AM/PM Option
Day 29: Staff Initials & Last Name

Clear
Day 29: Youth Initials

Clear
Day 29 Comments
Day 29: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 30: Time

Hour Minutes

AM/PM Option
Day 30: Staff Initials & Last Name

Clear
Day 30: Youth Initials

Clear
Day 30 Comments
Day 30: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)
Day 31: Time

Hour Minutes

AM/PM Option
Day 31: Staff Initials & Last Name

Clear
Day 31: Youth Initials

Clear
Day 31 Comments
Day 31: Daily Med Count
Number of Meds sent on pass (If applicable)
Number of Meds returned from pass (if applicable)

ARIZONA DEPARTMENT OF CHILD SAFETY

CONGREGATE CARE MEDICATION LOG

ARIZONA DEPARTMENT OF CHILD SAFETY

CONGREGATE CARE

MEDICATION LOG