North Dakota Attorney GeneralTake Back Program 2026

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The document is a Drug Disposal Log from the North Dakota State Board of Pharmacy, designed for facilities to record the destruction of medications. It includes fields for details such as the date dispensed, resident's name, pharmacy name, drug information, quantity, method of destruction, and signatures of witnesses and the consultant pharmacist. Facilities are instructed to complete and return this log at the end of each calendar quarter.

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Click ‘Get Form’ to open the North Dakota Attorney General Take Back Program document in the editor.
Begin by filling in the 'FACILITY' and 'STREET ADDRESS' fields at the top of the form. Ensure that all information is accurate for proper identification.
Next, circle the appropriate calendar quarter that corresponds to when you are submitting this form. This helps in organizing records effectively.
In the table provided, enter details for each destroyed medication. Fill in the 'Date Dispensed', 'RX #', 'RESIDENT'S NAME', 'NAME OF PHARMACY', and 'DRUG'.
For each entry, specify the 'Quantity', 'Strength', and 'METHOD OF DESTRUCTION'. This ensures compliance with disposal regulations.
Finally, have two witnesses sign in the designated areas and ensure that a consultant pharmacist's name is included under 'DESTROYED BY'.

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