Free Cancer and Chronic Diseases Drug Repository Program Donation, Transfer, and Destruction Record-F-62644 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62644 (Rev. 07/08)

STATE OF WISCONSIN

CANCER AND CHRONIC DISEASES DRUG REPOSITORY PROGRAM DONATION, TRANSFER, AND DESTRUCTION RECORD


Completion of this form meets the requirements of Wisconsin Administrative Codes HFS 148.06(2)(a)1 and (b)3 for donating drugs and supplies, HFS 148.09(3) for distribution of drugs or supplies to a participating repository, and HFS 148.11(2) for destruction of drugs and supplies. Questions about completion of this form may be directed to 608-266-5388.



DONATION INFORMATION
Name ­ Donor (Print or type.) Date Donated

Name ­ Pharmacy or Medical Facility Receiving Donation

Name ­ Medication or Medical Supply

Medication Strength

Expiration Date

Quantity Donated

I attest that the above named medication or medical supply was stored as recommended by the manufacturer and has not been tampered with.
SIGNATURE ­ Donor
Date Signed

DRUG OR MEDICAL SUPPLY TRANSFER INFORMATION
Name ­ Pharmacy or Medical Facility Receiving Drug or Medical Supply Date Transferred

Quantity of Medication or Description of Medical Supply Transferred

Check one of the following: The original donation form is being sent with the transferred medication or medical supply if the entire original donation is transferred. A copy of the original donation form is being sent with the transferred medication if the original donation is partially transferred. DESTRUCTION INFORMATION
Name ­ Medication Quantity Destroyed

SIGNATURE ­ Person Destroying Medication

Date Destroyed