Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

TB/LTBI Medication Return Form
Reason for Return:
1 = Outdated 2 = Overstock 3 = Discontinued Medication 4 = Recalled Medication 5 = Lost to follow up 6 = Other
Patient Name
Qty
Returned
Drug Strength
Note: Please do not deface packaging prior to returning. Thank you.
Reason
for
Return
Stored
at PHC
Facility Name: ____________________________________ Location:______________________
Completed by: ___________________________________Date completed:__________________
Page _____ of _____
Return this completed form with inventory to:
Alaska DHSS/DPH Drug Room, 9210 Vanguard Dr Suite 102A, Anchorage, AK 99507.
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
For Drug Room
Use only
Rev 8/11