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					                                            Medication Disposal Record Instructions
Column 1 & 2 Date & Time: Fill in date and time medication is being disposed.
Column 3 Student Name: Fill in the name of the student whose medication is being disposed.
Column 4 Medication/Dose: Fill in the name of the medication and dose as listed on the pharmacy label.
Column 5 Amount Destroyed: Fill in amount of medication or number of pills being disposed.
Column 6 Reason: List the reason the medication is being disposed.
Column 7 Means: List how the medication is being disposed (see below).
Column 8 Staff Signature: Staff disposing of medication signs the form.
Column 9 Witness Signature: Staff witnessing the disposal signs the form.

Medication Disposal
There are no government guidelines for destroying medication. Pharmaceutical recommendations for the disposal of medications include:
             Return medication to the pharmacy or local hospital if they have a disposal program.
             Dispose of medication at your community household hazardous waste collection program.
             Dispose of medication in the garbage with the following precautions:
                 a. Scratch out the name for security purposes
                 b. Add some water to the pills, or an absorbent material like flour or cat litter to liquid medications.
                 c. Put the containers in a paper bag or other closed container to conceal them.
                 d. Put them in the garbage as close to trash pickup time as possible.
               Tennessee Department of Children’s Services
               Medication Disposal Record

                                                              Medication/         Amount
 Date         Time           Student Name                     Dose                Destroyed              Reason                 Means               Staff Signature   Witness Signature

Please disregard all previous versions prior to the date listed below. Always check the “Forms” Website for most current version. This form may not be altered.
Distribution: YDC Health Clinic, Group Home/Facility Record
CS-0712, Rev. 03/08                                                                                                                                                             Page 1 of 1

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