Form Approved
OMB Number 0935-0118
Expiration Date 01/31/2013
OMB
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DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
PRESS NEXT TO CONTINUE IN THIS EVENT FORM
PRESS BREAKOFF TO DISCONTINUE
DATE FILLED
Q1. Date Filled
Month:_____ Day:________ Year:_______
DK/REF/RETRIEVABLE -- CONTINUE TO Q2
PRESCRIPTION INFORMATION
Q2. Prescription information will be identified using:
NOTE: TRY TO OBTAIN NDC. USE DRUG NAME
ONLY IF NDC NOT AVAILABLE.
[IF Prescription Information = 1 (NDC), GO TO Q2a;
IF Prescription Information = 2 (Drug Name, Strength/Unit, & Dosage Form), GO TO Q2b]
Q2a. NDC
ENTER 11-DIGIT NDC WITHOUT DASHES OR SPACES.
NDC IS UNKNOWN OR REFUSED, RETURN TO PREVIOUS SCREEN AND SELECT DRUG NAME OPTION
________________
WHEN Q2a is COMPLETE, GO TO Q3a/QTY.
Q2b. Drug Name:
________________
WHEN DRUG NAME IS COMPLETE, SEND USER TO Q2c/STRENGTH.
Q2c. Strength
WHEN RECORDING STRENGTH, ENTER A WHOLE NUMBER OR A FRACTIONAL VALUE UP TO 3 DECIMAL POINTS. VALID ENTRIES INCLUDE 15, 3.5, 2.25, 0.333
________________
Q2d. Unit:
________________
Note: WHERE NECESSARY, YOU MAY ENTER A SECOND STRENGTH AND UNIT FOR EXAMPLE TO DESCRIBE A SOLUTION OR CONCENTRATION (e.g., 7 mg/5 ml). OTHERWISE SKIP TO Q2e DOSAGE FORM
Q2c2. Strength
________________
Q2d2. Unit:
________________
Q2e. Dosage Form:
________________
AFTER Q2e, CONTINUE TO Q3a/b.
Q2b - DK/REF/RETRIEVABLE -- CONTINUE TO Q2c/d
Q2c/d - DK/REF/RETRIEVABLE -- CONTINUE TO Q2e
Q2e - DK/REF/RETRIEVABLE -- CONTINUE TO Q3a/b
QUANTITY
Q3a. Quantity:
________________
WHEN RECORDING QUANTITY, ENTER A WHOLE NUMBER OR A FRACTIONAL VALUE UP TO 3 DECIMAL POINTS. VALID ENTRIES INCLUDE 100, 15, 3.5, 2.25, 0.333
NOTE 1: QUANTITY SHOULD REFLECT THE CONTENTS OF A CONTAINER, NOT THE NUMBER OF CONTAINERS.
EXCEPTION: IF NDC PROVIDED, THEN NUMBER OF EPIPENS CAN BE RECORDED FOR QUANTITY, AS OPPOSED TO QUANTITY OF EPIPEN CONTENTS.
NOTE 2: FOR A DEVICE, ACCEPT A QUANTITY OF 1 OR 2.
NOTE 3: FOR PILLS, A QUANTITY OF 1 OR 2 IS ACCEPTABLE BUT CONSIDER EXCEPTION BELOW BEFORE ENTRY.
EXCEPTION: IF IT APPEARS THE QUANTITY IS FOR ONE OR TWO DOSEPAKS CONTAINING MULTIPLE PILLS, THEN RECORD THE QUANTITY OF TABLETS, CAPSULES, ETC., THAT EACH DOSEPAK CONTAINS.
NOTE 4: FOR INHALERS, OINTMENTS, CREAMS, DROPS, LIQUID, FILLED SYRINGES (EXCEPT EPIPENS) AND OTHER DOSAGE FORMS NEEDING A QUANTITY UNIT, ASK FOR THE QUANTITY OF THE CONTENTS.
Q3b. Unit:
________________
Q3b -- DK/REF/RETRIEVABLE -- CONTINUE TO Q4
Q4. How many days were supplied?
IF PRESCRIPTION WAS TO BE USED “AS NEEDED” ENTER 999
________________
Q4 -- DK/REF/RETRIEVABLE -- CONTINUE TO Q5
PAYMENT INFORMATION
Q5. Patient Payment:
$________.____
Q5a. Were there any 3rd party payers?
Q6. Type of 3rd Party Payer
________________
Q7. 3rd Party Payment
$________.____
NOTE: IF PATIENT PAYMENT WAS $1 OR LESS, EXPECT THE 3rd PARTY PAYER TO BE A PUBLIC PROGRAM, E.G., MEDICAID OR OTHER STATE/LOCAL GOVT, ETC.
Any more 3rd Party Payers?
1 YES
2 NO
Q6/Q7 - ALLOW A MAXIMUM OF TWO 3rd PARTY PAYERS. IF USER SAYS “YES, MORE” THREE TIMES THEN THE PROGRAM WILL GO TO FINISH SCREEN.]
Q5 - DK/REF/RETRIEVABLE -- CONTINUE TO Q5a.
Q5a - DK/REF/RETRIEVABLE -- CONTINUE TO FINISH SCREEN.]
Q6 - DK/REF/RETRIEVABLE -- CONTINUE TO Q7.
Q7 - DK/REF/RETRIEVABLE -- CONTINUE TO FINISH SCREEN.]
FINISH SCREEN
PRESS VALIDATE TO COMPLETE THIS EVENT FORM.