Donor and recipient forms
||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:
||The name of the
person that was originally dispensed the drugs or the name of the terminal
distributor of dangerous drugs or drug distributor that owns the
||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 the responsible person's designee of a terminal
distributor of dangerous drugs or a drug distributor.
||The date the form
||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
||The brand name or generic name of the drug donated and
either the name of the manufacturer or the national drug code number
||The strength of the drug donated.
||The quantity of
the drug donated.
||The date the drug was donated.
to receiving donated drugs from a drug repository program, each recipient must
sign a form stating they understand the immunity provisions of the program
pursuant to division (B) of section
3715.872 of the Revised
Replaces: 4729-35-06, 4729-35-07
Cite as Ohio Admin. Code
Five Year Review (FYR) Dates:
Amplifies: 3715.87 ,
Effective Dates: 01/01/2004