MEDICATION PASS LOG 
Trainee Name:____________________ Job Title:__________________ Class Date:___________ 
Instructions: A “medication pass” is considered assisting every individual present with medication during one specific time period.  A trainee may only assist with one medication pass per shift (one shift = 8 hours). 
PASS #  TYPE(S) OF MEDICATION  DATE  TIME  RESULTS  COMMENTS  
.Oral .Ear .Topical .Eye Drops  .Vaginal/Rectal  __/___ pm/am  . Satisfactory .Further Instruction Required  
Observer Name:  Job Title  Sign:  
.Oral .Ear .Topical .Eye Drops  .Vaginal/Rectal  __/___ pm/am  . Satisfactory .Further Instruction Required  
Observer Name:  Job Title  Sign:  
.Oral .Ear .Topical .Eye Drops  .Vaginal/Rectal  __/___ pm/am  . Satisfactory .Further Instruction Required  
Observer Name:  Job Title  Sign:  
.Oral .Ear .Topical .Eye Drops  .Vaginal/Rectal  __/___ pm/am  . Satisfactory .Further Instruction Required  
Observer Name:  Job Title  Sign:  
.Oral .Ear .Topical .Eye Drops  .Vaginal/Rectal  __/___ pm/am  . Satisfactory .Further Instruction Required  
Observer Name:  Job Title  Sign:  

Agency Name: ______________________________________________ Site: _______________________________________________________ 
This Medication Pass Log is to be completed in addition to the Medication Pass Checklist. Agencies are expected to maintain copies of both of these documents for review.  

AAM: Division of Developmental Disabilities Services July 2008