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 2012 and revision date on the draft form. 

Current regulation requires a pharmacy or wholesaler to complete the currently adopted (2012 or 2014) version of the Self-Assessment form.  Please be advised, however, the board will accept completion of either the currently adopted version OR the draft version. The draft 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. 1/2021)
• Compounding Self-Assessment (17M-39 Rev. 1/2022)
• Hospital Pharmacy Self-Assessment (17M-14 Rev. 12/2021)
• Wholesaler Dangerous Drugs & Dangerous Devices Self-Assessment (17M-26 Rev. 12/2021)
• Automated Drug Delivery Systems (17M-112 Rev. 1/22)

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)