Free 51060.FH11 - Indiana

APPLICATION FOR APPROVAL TO UTILIZE ELECTRONIC DAILY DISPENSING SYSTEM
State Form 51060 (R / 2-06)

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Please complete and return this form to the address to the right.
Name of facility Address (number and street, city, state, and ZIP code) Telephone number Name of qualifying pharmacist Type of permit

INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2067 E-mail: [email protected]

Permit number E-mail address License number

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If applying for more than one pharmacy location, attach a list of the individual pharmacies and supply the same information requested above.
Proposed date of implementation of electronic records (month, day, year) Will the system be networked to a central computer? Type of system to be used Number of megabytes of disk storage

Yes
If so, where is the central location?

No

Will the system be in compliance with 856 IAC 1-29-3?

Will the data referenced in 856 IAC 1-29-3 be readily retrievable?

Yes
Does the system date and time the information when entered?

No
Does the system identify the individual entering the information?

Yes Yes

No No

Yes
Can the information in the system be altered after it is entered?

No No

Yes

If yes, please read the following information and explain the modifications that will be allowed.

If modifications are allowed, the system must include an audit trail to identify the circumstances surrounding any modifications specifying who made the alteration, an explanation and date of change.
Will the system meet the above requirement?

Yes
Describe the audit trail process the system will utilize.

No

The system is required to have the capability of information back up. Will this back-up material be stored in a secure and readily retrievable location? [Refer to 856 IAC 1-29-3(d)]

Yes

No

(Continued on the reverse side.)

In the event of system down time, what auxiliary procedure will be used for documentation of prescription orders? (Refer to856 IAC 1-29-4)

Does any department entity outside of the pharmacy have access to the data in the pharmacys system? If so, please explain who and why.

I hereby swear or affirm under the penalties of perjury that the above statements are true and correct and that the system in questions complies with the minimum requirements set out at 856 IAC 1-29 and Title 21 of Code of Federal Regulations at sections 1306.22.
Signature of applicant Printed name of applicant E-mail address Telephone number Fax number Title Date (month, day, year)

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