Medication/Medical Supply:

Manufacturer/NDC #:

Drug Strength & Dosage Form:

Expiration Date:

Quantity:

Lot # (if available):

Medication/Medical Supply:

Manufacturer/NDC #:

Drug Strength & Dosage Form:

Expiration Date:

Quantity:

Lot # (if available):

Medication/Medical Supply:

Manufacturer/NDC #:

Drug Strength & Dosage Form:

Expiration Date:

Quantity:

Lot # (if available):

Donor - Name and Address:

Donor - Phone:

Donor’s Representative - Name and Address:

Donor - E-mail:

I certify that the medications or medical supplies listed on this form were stored as recommended by the manufacturer and have not been tampered with:

My donation...

Is not a Controlled substance

Will not expire for at least 3 months

Is in sealed packaging (un-sealed amber vials are not accepted)

Does not require refrigeration

Completion of this form meets the requirements of Iowa Administrative Code 641 — 109.4(a, b, c, h) and 109.4 (5a, b, c) for donating drugs and supplies

*Drugs and biological products for which the Federal Food and Drug Administration (FDA) requires a Risk Evaluation and Mitigation Strategy (REMS) with an element to assure safe use OR an implementation system, and such drugs and biological products as determined by the pharmacist in charge, shall not be accepted or distributed under the provisions of the program.

Signature - Donor or Donor’s Representative:

Date Donated:

Signature - Donor or Donor’s Representative:

Date: