Donor Participation Form

11100 Aurora Ave, Bldg. 13 Urbandale, Iowa, 50322
Phone: 1-866-282-5817
Fax: (515) 327-5422
www.safenetrx.org 

Iowa Drug Donation Repository Program Donor Participation
Completion of this form meets the notification requirement to prescribe and/or dispense prescription medications as part of the prescription drug donation repository program under Iowa Administrative Code 641—109.3. Questions about completing this form may be directed to kenzie.harder@safenetrx.org.

Pharmacy or Medical Facility
Name of Pharmacy, Medical Facility, or Other Donor Site:
Telephone Number:
Address:
City:
State:
Zip Code:
Name - Pharmacist, Physician, Nurse Practitioner, Program Manager:
Telephone Number:
State License/Registration Number:
Name of Agency/Board Issuing/Registration Number:
I am the pharmacist, physician, or nurse practitioner in charge of the pharmacy or medical facility listed above. The pharmacy or medical facility is in compliance with all applicable federal and state laws including those related to the storage and distribution of drugs and holds an active non-restricted state issued license in good standing. I have read the attached rules related to the repository program and agree that this pharmacy or medical facility shall comply with such rules.

Signature - Pharmacist, Physician, Nurse Practitioner, Program Manager:
Date:
Primary Contact Information
*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.
Name of Primary Contact for Drug Donation Program Communication:
Primary Contact Phone Number:
Primary Email Address:
Primary Contact Fax Number
I agree NOT to donate (check yes or no):
  • Controlled substances
  • Drugs that appear to have been adulterated, broken, or disintegrated
  • Drugs subject to REMS criteria with an element to assure safe use and an implementation system
  • Drugs requiring temperature control other than “room temperature storage"
By checking this box you have read our program rules here

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