DJJ Form HS054 "Non-licensed Staff Medication Record (For Youth During Transport)" - Florida

Form HS054 is a Florida Department of Juvenile Justice form also known as the "Non-licensed Staff Medication Record (for Youth During Transport)". The latest edition of the form was released in September 1, 2010 and is available for digital filing.

Download an up-to-date Form HS054 in PDF-format down below or look it up on the Florida Department of Juvenile Justice Forms website.

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Download DJJ Form HS054 "Non-licensed Staff Medication Record (For Youth During Transport)" - Florida

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Florida Department of Juvenile Justice
NON-LICENSED STAFF MEDICATION RECORD (For Youth During Transport)
This form is to be completed for all youth transported off-site, who are prescribed medications that must be taken during transport.
It must be completed by the non-licensed staff member who is trained in Youth Assisted Self-Administration of Medication.
IF DURING TRANSPORT MEDICATION IS REQUIRED MORE THAN TWICE: REQUIRES LISTING OF MEDICATION TO BE REPEATED.
I received training in Youth Assisted Self Administration of Medication.
Originating Facility Name and Phone Number:
Date of Transport:
Youth Name:
DJJ#:
DOB:
Name of Medication
Directions on prescription, including
Date/Time
Initials of Staff
Date/Time
Initials of Staff
frequency/strength/quantity and time
Medication Self
Witnessing Self
Medication Self
Witnessing Self
last dose given.
Administered
Administration
Administered
Administration
Youth Signature:
Date:
63M-2
HS 054
9/2010
Page 1 of 1
Florida Department of Juvenile Justice
NON-LICENSED STAFF MEDICATION RECORD (For Youth During Transport)
This form is to be completed for all youth transported off-site, who are prescribed medications that must be taken during transport.
It must be completed by the non-licensed staff member who is trained in Youth Assisted Self-Administration of Medication.
IF DURING TRANSPORT MEDICATION IS REQUIRED MORE THAN TWICE: REQUIRES LISTING OF MEDICATION TO BE REPEATED.
I received training in Youth Assisted Self Administration of Medication.
Originating Facility Name and Phone Number:
Date of Transport:
Youth Name:
DJJ#:
DOB:
Name of Medication
Directions on prescription, including
Date/Time
Initials of Staff
Date/Time
Initials of Staff
frequency/strength/quantity and time
Medication Self
Witnessing Self
Medication Self
Witnessing Self
last dose given.
Administered
Administration
Administered
Administration
Youth Signature:
Date:
63M-2
HS 054
9/2010
Page 1 of 1
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