Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

How to use the TB/LTBI Medication Return Form:
Please include this form whenever you are returning any tuberculosis medication, whether it is Stock or
Patient Specific labeling.
Patient column: Write the patient’s name, or “Stock” if it is stock. If you are returning multiple
medications for one patient, a ditto mark is acceptable once you have written the name once.
Qty Returned column: Write the total number of tablets, capsules, or liquid mls. (i.e. 473ml)
Drug column: Write the name of the medication that you are returning. (i.e. Rifampin or RIF,
Isoniazid or INH)
Strength column: Write the strength of the tablet, capsule or liquid. (i.e. 100mg, 300mg or
50mg/5ml)
Reason for Return Column: Write the number code which corresponds to your reason for
return. Codes are listed at the top of the table. (i.e. 1=outdated, 6=other)
Stored at PHC column: Check or “X” the box that applies. When you return any medication, we
need to be aware of whether it has left your Health Center or Clinic. If it has been in the
patient’s possession, check “no.”
For Drug Room Use column: Do not use this column.
Please include your name, facility, city, and date.
If there are multiple forms in the return, please indicate the page number and total pages on each.
Please do not fax the form. Please do not forget to put the form in the box with the returns. It is
advisable to keep a copy for your records for 2 years. If you have questions about filling out this form
please contact the Drug Room at 341-2207.
Rev 8/11