Dcfs.nv.gov



DIVISION OF CHILD AND FAMILY SERVICES

Controlled Substance Count

__________________________________________________________________________________________

Medication, Dosage, Frequency

_____________________________________ __________________________________

Client Name Month/Year

* Each count requires two signatures for verification.

|Date |Time | Staff Signature |Staff Signature |Count |Remarks |

|1 | | | | | |

| | | | | | |

| | | | | | |

|2 | | | | | |

| | | | | | |

| | | | | | |

|3 | | | | | |

| | | | | | |

| | | | | | |

|4 | | | | | |

| | | | | | |

| | | | | | |

|5 | | | | | |

| | | | | | |

| | | | | | |

|6 | | | | | |

| | | | | | |

| | | | | | |

|7 | | | | | |

| | | | | | |

| | | | | | |

|8 | | | | | |

| | | | | | |

| | | | | | |

|9 | | | | | |

| | | | | | |

| | | | | | |

|10 | | | | | |

| | | | | | |

| | | | | | |

|11 | | | | | |

| | | | | | |

| | | | | | |

|12 | | | | | |

| | | | | | |

| | | | | | |

|13 | | | | | |

| | | | | | |

| | | | | | |

|14 | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

|Date |Time |Staff Signature |Staff Signature |Count |Remarks |

|15 | | | | | |

| | | | | | |

| | | | | | |

|16 | | | | | |

| | | | | | |

| | | | | | |

|17 | | | | | |

| | | | | | |

| | | | | | |

|18 | | | | | |

| | | | | | |

| | | | | | |

|19 | | | | | |

| | | | | | |

| | | | | | |

|20 | | | | | |

| | | | | | |

| | | | | | |

|21 | | | | | |

| | | | | | |

| | | | | | |

|22 | | | | | |

| | | | | | |

| | | | | | |

|23 | | | | | |

| | | | | | |

| | | | | | |

|24 | | | | | |

| | | | | | |

| | | | | | |

|25 | | | | | |

| | | | | | |

| | | | | | |

|26 | | | | | |

| | | | | | |

| | | | | | |

|27 | | | | | |

| | | | | | |

| | | | | | |

|28 | | | | | |

| | | | | | |

| | | | | | |

|29 | | | | | |

| | | | | | |

| | | | | | |

|30 | | | | | |

| | | | | | |

| | | | | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download