Medication Disposal Form
Individual
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which medication/drug to be disposed?
Dosage or quantity
Method of disposal
Date & Time of the last dosage
Date of Disposal
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Drug/medication expiration
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Disposal
Expired medication
Medication contamination
Physician order indicates discontination
Physician order changes medication dosage
Other
Supervisor name
First Name
Last Name
Witness name
First Name
Last Name
Signature of the Supervisor
Signature of the Witness
Submit
Should be Empty: