Request Form for Drug Use Consideration

Generic Name:

Routes (circle all that apply:)           PO        PR        SC        IM        IV         Topical

Rationale for requesting removal or exclusion:

Relevant Scientific Information

1.

2.

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For Committee Use Only:

Drug Reviewed by JHC on ____________________________________________

Members:

________Schwartz, Ira                 ________LaCoste, David

________Neary, Jack                  ________Sanford, Mary

________Sansone, Paul                ________Bidgood-Wilson, Mary

________Santos, Paul                 ________Brown, Jack

________Sobelson, Gary

DECISION

________Approved for General Use

________Restricted as Follows:

___________________________________________________

__________________________________________________

________Deferred

________Other

Reason(s:)________________________________________________