New Jersey Prescription Blanks (NJPBs) Incident Report

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Information about Person Reporting the Incident
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Prescriber Information
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Define Incident
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Description
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Details
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Additional Information
Information About Person Reporting the Incident
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Prescriber or Facility Information
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Define Incident
The NJPBs involved in this incident were...
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Description
If any of the information requested below is unknown, please write “unknown”.
Has the incident involving the missing NJPBs been reported to any law enforcement, governmental agency or professional licensing board?
Reported to:
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Details
List of perpetrator(s) involved in the incident
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Was the person involved in the incident arrested?
Check whether the medication involved in the incident was a:
Was an attempt to bill a Third Party Prescription Program for the medication involved in the incident?
Was the third party administrator notified of the incident?
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Additional Information
Enter the pharmacy or pharmacies where the missing blanks were reported as having been presented to the filled:
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(If your response is longer than 5000 characters, you may upload it as a document after submitting the report)
5000 chars left / 5000 character max
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