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

What Is DJJ Form HS054?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2010;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DJJ Form HS054 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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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