Donor Participation Form

1500 SE 19th Street, Suite 530, Grimes, IA 50111
Phone: 1-866-282-5817
Fax: (515) 327-5422
www.safenetrx.org

Name of Pharmacy, Medical Facility, or Other Donor Site:
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

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

SafeNetRx is a 501(c)3 non-profit organization with a mission to serve vulnerable populations through responsible collection and distribution of donated medicines.

SafeNetRx

1500 SE 19th St, Ste 530, Grimes, IA 50111

Phone: 1-866-282-5817
Fax: 515-327-5422
Email: repository@safenetrx.org

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Drug Donation Repository

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Donor Participation Form

Iowa Drug Donation Repository Program Donor Participation

Pharmacy or Medical Facility

Primary Contact Information