NJPB Form II-A
Revised 4/14
Send to:
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Drug Control Unit - NJPB
124 Halsey Street, 6th oor, P.O. Box 45045
Newark, New Jersey 07101
Telephone: 973-504-6200
Fax: 973-504-6326
E-mail: NJPB@dca.lps.state.nj.us
CertifiCation of the DestruCtion
of New Jersey Prescription Blanks (NJPBs)
Date:
Person destroying NJPBs:
Name: ________________________________________________________
Title: _________________________________________________________
Afliation:_____________________________________________________
(Name of prescriber or healthcare facility)
Street address: _________________________________________________
City:___________________ State: ____________ ZIP code: ____________
Telephone #: ______________________Fax #: ______________________
(include area code) (include area code)
E-mail address:_________________________________________________
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 separate certication form must be used for each unique batch number or unique order month (15 digit ID). A photocopy
of the rst and last serial numbers for the NJPBs in the batch must be submitted with this certication. 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 completed and signed form
along with the NJPB copies, must be e-mailed or mailed to the Drug Control Unit at the above address. If mailing in the
certication form and documents, please retain a copy of your submission for your records.
I. Description of the NJPB Destroyed
Name of prescriber(s) or healthcare facility appearing on the NJPB:
__________________________________________________________________________________________________________
Professional license number(s) or healthcare facility provider number appearing on the NJPB: __________________________
Street address: ______________________________________________________________________________________________
City, State, ZIP code: ________________________________________________________________________________________
Telephone #: ______________________________ (include area code) Fax #: ______________________________ (include area code)
DEA #: _________________________ Batch #: __________________________ Serial #: Start ______________End: ___________
Quantity destroyed: ______________ Date of destruction: ________________ 15 Digit ID #: Start _________End: ___________
II. Reason for Destruction
Check applicable incident and complete section III. Method of Destruction of this form.
Unused blanks Board Order Damaged/Spoiled Other (Please attach a detailed description to this form.)
III. Method of Destruction
Pulp Shred Incinerate Pulverize
IV. Comments
If you have additional comments, please attach a detailed explanation to this form.
Witness Certication
I, ________________________________________ (print name), being of full age, certify and say under penalty of false
statement, that I am the person described and identied in this certication; that the information given in this certication
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 certication 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 certication.
_________________________________ ________________________________ _________________________________
Name
of witness (print) Title of witness (print) Signature of witness to destruction of NJPBs
Street address: _____________________________________________________________
City, State, ZIP code: _______________________________________________________
click to sign
signature
click to edit
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