DJJ Form HS053 "Medication Receipt, Transfer & Disposition Form" - Florida

Form HS053 is a Florida Department of Juvenile Justice form also known as the "Medication Receipt, Transfer & Disposition Form". The latest edition of the form was released in September 1, 2010 and is available for digital filing.

Download a PDF version of the Form HS053 down below or find it on Florida Department of Juvenile Justice Forms website.

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Download DJJ Form HS053 "Medication Receipt, Transfer & Disposition Form" - Florida

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MEDICATION RECEIPT, TRANSFER & DISPOSITION FORM
Please complete this form when a youth is discharged from a facility or transported to another facility. Medications must be in the original pharmacy container. The Youth’s Name, Physician, Medication
Name and Dosage must be legible on the label. There can be no changes written on the label. Any medication brought into the facility that is not in the original container cannot be accepted
Name of Youth
Youth’s Name:
DJJID#:
DOB:
Allergies:
Originating Facility
Facility/Program Name:
Address, City, State:
Phone #:
Destination Facility
Facility/Program Name:
Address, City, State:
Phone #:
Chain of Custody for Medication (See Attached Transport Card)
Date
Time
Staff Name/Title
Signature
(Printed)
Medication Transfer Receipt
Name of Medication
Strength
Quantity
Prescribing Physician
Telephone #
Verified
Staff Initials
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
INTAKE MEDICATIONS RECEIPT:
(COMPLETE THIS PORTION - Bringing medications from home)
Printed Name of Person Delivering Medications:
DJJ Staff
Parent/Guardian Releasing Medications
Delivery Signature:
Facility/Parent Contact #:
Youth, if 18, or  DCF
Printed Name/Title of Person Accepting Medication(s):
DJJ Staff
Parent/Guardian
Signature of Person Receiving Medications:
Witness Printed Name/Signature:
FOR THE PURPOSE OF RELEASE: I understand that these medications are not in a child-proof, safety container, and I agree to accept these medications without a child-proof, safety container. I
understand that if I do not agree to accept these medications without a child-proof, safety container, the DJJ representative is not authorized to provide me with any medications. In consideration of
agreeing to accept these medications in a non-child-proof, non-safety container, I assume full and complete responsibility for the use and storage of medications from this date forward.
Pending Appointments:
63M-2
HS 053
9/2010
Page 1 of 1
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MEDICATION RECEIPT, TRANSFER & DISPOSITION FORM
Please complete this form when a youth is discharged from a facility or transported to another facility. Medications must be in the original pharmacy container. The Youth’s Name, Physician, Medication
Name and Dosage must be legible on the label. There can be no changes written on the label. Any medication brought into the facility that is not in the original container cannot be accepted
Name of Youth
Youth’s Name:
DJJID#:
DOB:
Allergies:
Originating Facility
Facility/Program Name:
Address, City, State:
Phone #:
Destination Facility
Facility/Program Name:
Address, City, State:
Phone #:
Chain of Custody for Medication (See Attached Transport Card)
Date
Time
Staff Name/Title
Signature
(Printed)
Medication Transfer Receipt
Name of Medication
Strength
Quantity
Prescribing Physician
Telephone #
Verified
Staff Initials
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
INTAKE MEDICATIONS RECEIPT:
(COMPLETE THIS PORTION - Bringing medications from home)
Printed Name of Person Delivering Medications:
DJJ Staff
Parent/Guardian Releasing Medications
Delivery Signature:
Facility/Parent Contact #:
Youth, if 18, or  DCF
Printed Name/Title of Person Accepting Medication(s):
DJJ Staff
Parent/Guardian
Signature of Person Receiving Medications:
Witness Printed Name/Signature:
FOR THE PURPOSE OF RELEASE: I understand that these medications are not in a child-proof, safety container, and I agree to accept these medications without a child-proof, safety container. I
understand that if I do not agree to accept these medications without a child-proof, safety container, the DJJ representative is not authorized to provide me with any medications. In consideration of
agreeing to accept these medications in a non-child-proof, non-safety container, I assume full and complete responsibility for the use and storage of medications from this date forward.
Pending Appointments:
63M-2
HS 053
9/2010
Page 1 of 1
Save As
Reset/Clear Form
Print Page
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