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Get Nj Njpb Incident Report 2018-2024

Has been reported to the following law enforcement agency governmental agency or professional licensing board 1 Name Person PB Form 1 Revised 2/12 Page 1 Section IV. Section I. - Personal Information Name of Prescriber and Professional Degree or Name of Healthcare Facility appearing on the involved NJPB form. Professional License Number or Healthcare Facility Provider Number appearing on the involved NJPB form. Street address City State County and ZIPcode Section II. - The Incident that occurred involves Check Applicable Incident and as appropriate complete Sections III IV and V of this form. Misplaced Lost Forged Stolen Altered Lost in Delivery Other Describe below Damaged Counterfeit Section III. State. nj. us Please print clearly. From Identify Person Reporting Incident Name and Title Prescriber/Healthcare Facility/Printer/Pharmacist/Law Enforcement Agency/Other Address Telephone number include area code Fax number include area code Include a copy of the RX if available along with a written narrative of the specific circumstances and a copy of the police report if reported. Section I. - Personal Information Name of Prescriber and Professional Degree or Name of Healthcare Facility appearing on the involved NJPB form. Professional License Number or Healthcare Facility Provider Number appearing on the involved NJPB form. Street address City State County and ZIPcode Section II. - The Incident that occurred involves Check Applicable Incident and as appropriate complete Sections III IV and V of this form. Misplaced Lost Forged Stolen Altered Lost in Delivery Other Describe below Damaged Counterfeit Section III. - Description The number of missing NJPB s is estimated to be Batch number Serial number The name of the printer from whom the NJPB s were purchased The Incident involving the missing NJPB s Has not been reported to any law enforcement agency governmental agency or professional licensing board. NJPB INCIDENT REPORT Date of report Date of incident Send To State of New Jersey Office of Drug Control-NJPB Unit P. O. Box 45045 Newark New Jersey 07101 Telephone 973 504-6593 or 973 792-4240 Fax 973 504-6326 E-Mail collinsc dca.lps. state. nj. us Please print clearly. From Identify Person Reporting Incident Name and Title Prescriber/Healthcare Facility/Printer/Pharmacist/Law Enforcement Agency/Other Address Telephone number include area code Fax number include area code Include a copy of the RX if available along with a written narrative of the specific circumstances and a copy of the police report if reported. Please provide a copy of the RX if available along with a written narrative of the specific circumstances with this report. The policy number 6. Was the third party administrator notified of the Incident Section V. - Additional Information A. - Details A. List the perpetrator s involved in the Incident and provide each individual s name address telephone number and date of birth. Date of birth B. Was the person involved in the Incident arrested If Yes enter Yes No 1. Name of law enforcement agency 4.

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