Get Medication Incident Report Form

Filing a Medication Incident Report is a crucial step in addressing medication errors and ensuring student safety. This comprehensive guide will walk you through each section of the report form, providing clear instructions for submitting it online.

Follow the steps to complete the Medication Incident Report Form effectively.

1. Select the ‘Get Form’ button to access the Medication Incident Report Form and open it in an online editor.
2. Begin by filling in the 'Date of Report' field with the current date. Make sure to use the format month/day/year.
3. Enter the student's name accurately in the designated field to ensure clarity.
4. Provide the name of the parent or guardian, along with their contact phone number. This information is crucial for follow-ups.
5. Complete the home address section, ensuring accuracy in street, city, state, and zip code fields.
6. Indicate the name of the teacher or human resources representative associated with the student.
7. Record the date of the medication error in the specified format (month/day/year).
8. Fill in the time the error occurred, selecting between AM and PM as appropriate.
9. Input the name of the licensed prescriber responsible for the medication.
10. Specify the medication involved in the incident, including dose and route of administration.
11. Provide a detailed description of the error and how it occurred. If more space is needed, use the reverse side of the form.
12. Indicate whether the licensed prescriber was notified of the incident by selecting yes or no.
13. Also note if the parent or guardian was informed, and document the names and details of any other persons who were notified.
14. Include the dates and times when notifications were made, ensuring to specify AM or PM.
15. Describe the outcome of the incident thoroughly, providing all relevant information.
16. Print the name of the person completing the form and their title in the designated fields.
17. Finally, provide your signature and the date on which the form is signed.
18. Once all fields are completed, save your changes, then download, print, or share the form as needed.

Complete your Medication Incident Report Form online efficiently today!