Medicines usage report (MPA-70MUR)

Under Section 70 of the Medicines and Poisons Act 2019 (MPA), a substance authority is subject to any additional condition decided by the chief executive. Further, section 71 of the MPA requires that a person to whom a substance authority applies must comply with the conditions of the authority unless the person has a reasonable excuse.

Certain substance authorities granted under the Medicines and Poisons (Medicines) Regulation 2021 (MPMR) are subject to the condition that the holder must periodically report medicines usage to the chief executive of Queensland Health (or delegate) — this form must be used for this purpose.

Privacy notice

Before completing this form, please carefully read the following Privacy Statement:

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 notice under authority of the Medicines and Poisons Act 2019. The information is being collected to ensure that health risks arising from the use of regulated substances are appropriately managed. All personal information will be securely stored and only accessible by Queensland Health. Your personal information will not be disclosed to any other third parties without consent unless the disclosure is authorised or required by 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.

Contact information

This notice is managed by the Healthcare Approvals and Regulation Unit (HARU). Should you require assistance in completing this form, please email: HARU@health.qld.gov.au.

Required fields are marked with an asterisk (*).

1. Details of person making the notification

Title

Given name *

Surname *

Position *

Work phone *

Work email *

2. Details of substance authority holder making the notification

Entity name *

Substance Authority Reference *

Expiry date *

Day Month Year

Type of substance authority held

3. Details of medicines usage

Site/event/location *

Reporting period beginning

Day Month Year

Reporting period ending

Day Month Year

Provide details of any medicines held at, or taken to, the site/event/location over the reporting period

Generic name of substance	Quantity	Measure	Form	Strength

Were any medicines used during this reporting period for this site/event/location *

Provide details of any medicines used at the site/event/location over the reporting period

Date	Generic name of substance	Qualification	Prescriber's instruction	Further details
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year

4. Additional information and attachments

Additional information

Upload additional supporting documents

Certification *

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

MPA-70MUR, Version 1

Last updated: 4 December 2023