Certificate of Destruction of New Jersey Prescription Blanks (NJPBs)

Person Destroying New Jersey Prescription Blanks (NJPBs)

Consistent with the security objectives of the Uniform Prescription Act, all prescribers or healthcare facilities using New Jersey Prescription Blanks (NJPBs) must notify the Division of Consumer Affairs’ Drug Control Unit of the destruction of NJPBs. The person who shall witness the destruction of the prescriber/healthcare facility NJPBs, shall complete this form. Note: The person destroying the NJPBs cannot be the same person who witnesses the destruction.

A certification of destruction must be submitted for each unique batch number or unique order month (15 digit ID). A photocopy of the first and last 15-digit identifying numbers for the NJPBs in the batch must be submitted with this certification. Acceptable means of destruction include shredding, burning, pulping, or pulverizing the NJPBs so that every NJPB is rendered essentially unreadable, indecipherable, and otherwise cannot be reconstructed. Upon destruction, this certification of destruction must be completed. Please retain a copy of your submission for your records.

Description of the New Jersey Prescription Blanks Destroyed
Reason for Destruction
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Method of Destruction
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Witness Certification
I certify being of full age, certify and say under penalty of false statement, that I am the person described and identified in this certification, that the information given in this certification and all submitted materials contain no willful misrepresentations and that the information is true and complete. I understand that should an investigation at any time disclose otherwise, I and/or the licensee may face legal sanctions. I understand that in signing this certification of destruction, I am consenting to any reasonable inquiry that may be necessary to verify the information that I have provided on this form or may provide in conjunction with this certification.