Florida Board of Pharmacy Compounding Survey

Pharmacy Name:
Pharmacy Address:
Pharmacy Permit Number:
Email Address:

1. Does your pharmacy hold a permit in any state other than Florida?
Yes
No

1a. If yes, in which other state(s) does your pharmacy hold a pharmacy permit (check all that apply)?
AL   AK   AZ   AR   CA   CO   CT   DE   DC   GA   HI   ID   IL   IN   IA   KS   KY   LA   ME   MD   MA   MI   MN   MS   MO   MT   NE   NV   NH   NJ   NM   NY   NC   ND   OH   OK   OR   PA   RI   SC   SD   TN   TX   UT   VT   VA   WA   WV   WI   WY

2. Pharmacy permit type (check all that apply):
Central Fill
Class II Institutional
Community
Internet
Modified Class II Institutional
Non-Resident
Nuclear
Special Closed System
Special ESRD
Special Limited Community
Special Parenteral/Enteral
Special Parenteral/Enteral Extended Scope
None of the above (If you are permitted as an Animal Control Shelter, Institutional Class I Nursing Home, or Assisted Living Facility, you are not authorized to compound. The survey is complete; please submit.)

3. Is your pharmacy currently registered, licensed, or permitted as a pharmaceutical manufacturer in any state?
Yes
No

3a. If yes, which state(s) is your pharmacy currently registered, licensed, or permitted as a pharmaceutical manufacturer (check all that apply)?
AL   AK   AZ   AR   CA   CO   CT   DE   DC   FL   GA   HI   ID   IL   IN   IA   KS   KY   LA   ME   MD   MA   MI   MN   MS   MO   MT   NE   NV   NH   NJ   NM   NY   NC   ND   OH   OK   OR   PA   RI   SC   SD   TN   TX   UT   VT   VA   WA   WV   WI   WY

4. Is your pharmacy currently registered, licensed, or permitted as a wholesale distributor in any state?
Yes
No

4a. If yes, in which state(s) is your pharmacy currently registered, licensed, or permitted as a wholesale distributor (check all that apply)?
AL   AK   AZ   AR   CA   CO   CT   DE   DC   FL   GA   HI   ID   IL   IN   IA   KS   KY   LA   ME   MD   MA   MI   MN   MS   MO   MT   NE   NV   NH   NJ   NM   NY   NC   ND   OH   OK   OR   PA   RI   SC   SD   TN   TX   UT   VT   VA   WA   WV   WI   WY

Non-Sterile Compounding

5. Does your pharmacy compound non-sterile products?
Yes
No

5a. If yes, what percentage of your business is related to non-sterile compounding?
Less than 10%
11% to 25%
26% to 50%
51% to 75%
Greater than 75%

5b. If yes, what types of non-sterile products do you compound (check all that apply)?
Creams
Lotions
Ointments
Mouthwash
Liquids
Drops
Capsules
Troches
Suppositories
Tablets
Gels
Other:

5c. If yes, do you compound (check all that apply)?
pursuant to a patient-specific prescription
in bulk (compounding multiple doses from a single source or batch)
in bulk for office use

5d. If you answered "yes" to compounding in bulk, would your largest single batch include:
24 or less doses from a single batch
25 to 49 doses from a single batch
50 to 100 doses from a single batch
Greater than 100 doses from a single batch

6. Does your pharmacy ship non-sterile compounded products to other states?
Yes
No

6a. If yes, in which state(s) does your pharmacy ship (check all that apply)?
AL   AK   AZ   AR   CA   CO   CT   DE   DC   FL   GA   HI   ID   IL   IN   IA   KS   KY   LA   ME   MD   MA   MI   MN   MS   MO   MT   NE   NV   NH   NJ   NM   NY   NC   ND   OH   OK   OR   PA   RI   SC   SD   TN   TX   UT   VT   VA   WA   WV   WI   WY

7. Has your company ever recalled a non-sterile compounded product due to compounding error?
Yes
No

7a. If yes, list the name(s) of the drug and the reason for the recall.

7b. If yes, did the recall occur:
Within the last six months
Greater than six months and less than one year
More than one year

Sterile Compounding

8. Does your pharmacy compound sterile products?
Yes
No

8a. If yes, what percentage of your business is related to sterile compounding?
Less than 10%
11% to 25%
26% to 50%
51% to 75%
Greater than 75%

8b. If yes, what types of sterile products do you compound (check all that apply)?
Total Parenteral Nutrition (TPN) solutions
Parenteral analgesic drugs
Parenteral antibiotics
Parenteral antineoplastic agents
Parenteral electrolytes
Parenteral vitamins
Irrigating fluids
Ophthalmic preparations
Aqueous inhalant solutions for respiratory treatments
Other:

8c. If yes, do you compound (check all that apply)?
pursuant to a patient-specific prescription
in bulk (compounding multiple doses from a single source or batch)
in bulk for office use

8d. If you answered "yes" to compounding in bulk, would your largest single batch include:
24 or less doses from a single batch
25 to 49 doses from a single batch
50 to 100 doses from a single batch
Greater than 100 doses from a single batch

9. Does your pharmacy ship sterile compounded products to other states?
Yes
No

9a. If yes, to which state(s) does your pharmacy ship (check all that apply)?
AL   AK   AZ   AR   CA   CO   CT   DE   DC   FL   GA   HI   ID   IL   IN   IA   KS   KY   LA   ME   MD   MA   MI   MN   MS   MO   MT   NE   NV   NH   NJ   NM   NY   NC   ND   OH   OK   OR   PA   RI   SC   SD   TN   TX   UT   VT   VA   WA   WV   WI   WY

10. Total number of pharmacy staff:
Pharmacists:
Technicians:
Interns:

11. Total number of pharmacy staff preparing sterile products:
Pharmacists:
Technicians:
Interns:

12. How many clean rooms are in your pharmacy?
Number of clean rooms:

13. How many laminar flow hoods are in your pharmacy?
Number of laminar flow hoods:

14. When was the last time your clean room was certified by an independent contractor for National Sanitation Foundation Standard 49?
Less than six months
Six months to one year
Greater than one year

14a. What is the name and address of the independent contractor certifying your clean room?

15. When was the last time your laminar flow hood was certified by an independent contractor for National Sanitation Foundation Standard 49?
Less than six months
Six months to one year
Greater than one year

15a. What is the name and address of the independent contractor certifying your laminar flow hood?

16. Has your company ever recalled a sterile compounded product due to compounding error?
Yes
No

16a. If yes, list the name(s) of the drug and the reason for the recall.

16b. If yes, did the recall occur:
Less than six months
Six months to one year
Greater than one year

If you are a Non-Resident Pharmacy please proceed to the next section. If you are NOT a Non-Resident Pharmacy, the survey is complete; please submit.

Non-Resident Pharmacies

17. Does the state in which you are physically located allow compounding?
Yes
No

17a. If yes, does your state permit compounding (check all that apply)?
pursuant to a patient-specific prescription
in bulk (compounding multiple doses from a single source or batch)
in bulk for office use

17b. If you answered "yes" to compounding in bulk, would your largest single batch include:
24 or less doses from a single batch
25 to 49 doses from a single batch
50 to 100 doses from a single batch
Greater than 100 doses from a single batch

17c. When was your pharmacy last inspected by your state regulatory authority?
Less than six months
Six months to one year
Greater than one year

DH-MQA 1308, 11/12, Rule 64B16ER12-1, FAC