Self-Assessment Forms

The assessment shall be performed before July 1 of every odd-numbered year. The self-assessment forms must remain on-site at the facility. Only submit the form to the board if requested by board staff.

The board is in the process of updating the Self-Assessment forms through a formal rulemaking.  The updates include references to statutory and regulatory changes that occurred between 2014 and 2016.  The last time the forms were formally updated was 2014.
Current regulation requires a pharmacy or wholesaler to complete the 2014 version of the Self-Assessment form.  Please be advised, however, the board will accept completion of either the 2014 version OR the 2016 version.  The latter version is likely to be a more helpful assessment to the pharmacy or wholesaler completing it.

Draft Self-Assessment Forms (Under Review for Possible Adoption)

• Community Pharmacy / Hospital Outpatient Self-Assessment (17M-13 Rev. 10/16)
• Compounding Self-Assessment (17M-39 Rev. 12/16)
• Hospital Pharmacy Self-Assessment (17M-14 Rev. 10/16)
• Wholesaler Dangerous Drugs & Dangerous Devices Self-Assessment (17M-26 Rev. 10/16)

Current Adopted Self-Assessment Forms

• Community Pharmacy Self Assessment (17M-13, Rev. 10/14)
• Compounding Self-Assessment (17M-39, Rev. 02/12)
• Hospital Outpatient Pharmacy Self-Assessment (17M-13, Rev. 10/14)
• Hospital Pharmacy Self-Assessment (17M-14, Rev. 10/14)
• Wholesaler Self-Assessment (17M-26, Rev. 10/14)