Reporting lost or stolen medicine - Additional medicines - s226 MPMR

This form must be used to report additional lost or stolen medicine to the chief executive pursuant to section 226 of the Medicines and Poisons (Medicines) Regulation 2021 (MPMR). This form must only be used if there is insufficient space on the online form Reporting lost or stolen medicines - s226 MPMR | Queensland Health.

You may be contacted by an inspector appointed under the Medicines and Poisons Act 2019 or an authorised delegate of the chief executive to require further information and/or for auditing/inspection purposes relevant to this notice.

If, at this stage, you are not able to provide all the information in this notice, you must give as much information as possible and you can provide any additional information when available.

Contact information

This notice is managed by Medicines Compliance. If you require assistance in completing this form, please email: MedicinesCompliance@health.qld.gov.au

Privacy notice

Personal information collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. Queensland Health is collecting your personal information on this approved form under authority of section 226 of the MPMR. All personal information will be securely stored and only accessible by Queensland Health staff. Your personal information will not be disclosed to other third parties without consent, unless the disclosure is authorised or required under law. Failure to provide information may render the form incomplete, which may constitute an offence under the Medicines and Poisons Act 2019. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au/global/privacy.

Required fields are marked with an asterisk (*).

Please provide the Initial Notification Submission ID number *

Please provide your details

First name *

Last name *

AHPRA registration (if applicable)

Role within the business / organisation *

Contact number *

Email address *

Additional details of medicines that were lost or stolen in this incident

Information: Medicine/s should be listed using only the terms used in the Australian Standard of Uniform Scheduling of Medicines and Poisons (SUSMP/Poisons Standard). These terms do not include brand names of products, they only refer to active ingredients. If a substance is not listed in the SUSMP/Poisons Standard but is a derivative of one that is listed in the SUSMP, then select the substance that is listed

SUSMP/Poisons Standard: https://www.tga.gov.au/publication/poisons-standard-susmp

List all the additional medicine/s that were lost or stolen in this incident in the below table

Medicine	Unit description	Strength	Strength unit	Total number of units

Certification

Certification *

In giving this notice, I affirm that the information I have supplied is, to the best of my knowledge, true and accurate

Last updated: 13 October 2021