(A) Each donor must sign a form stating that the donor is the owner of the drug and intends to voluntarily donate the drug to the drug repository program. The donor form must be completed prior to any donation and include at least the following:
(1) The name of the person that was originally dispensed the drugs, or the name of the terminal distributor of dangerous drugs or wholesale distributor of dangerous drugs that owns the drugs.
(2) The signature of the donor, which may include the person designated by durable power of attorney, a guardian, an individual responsible for the care and well-being of a patient, or the signature of the responsible person or his/her designee from a terminal distributor of dangerous drugs or a wholesale distributor of dangerous drugs.
(3) The date the form was signed.
(B) The following donor information must also be documented. This information may be documented on the original signed donor form or on an alternate record. If an alternate record is used, the record must include the name of the donor in addition to the required information in this paragraph.
(1) The brand name of the drug donated, or the generic name and list either the name of the manufacturer or the national drug code number (NDC#).
(2) The strength of the drug donated.
(3) The quantity of the drug donated.
(4) The date the drug was donated.
119.032 review dates:
Promulgated Under: 119.03
Statutory Authority: 3715.873 , 4729.26
Rule Amplifies: 3715.87 , 3715.871 , 3715.872 , 3715.873
Prior Effective Dates: 1/1/2004