Medication REMS Compliance Checklist Form
Complete this checklist to track and document required REMS compliance tasks for medication management.
Medication Name
*
Lot or Batch Number (if applicable)
Checklist of REMS Compliance Tasks
*
Reviewed current REMS requirements for this medication
Verified prescriber certification (if required)
Confirmed patient enrollment (if required)
Provided required patient counseling materials
Documented dispensing in REMS system (if required)
Reported adverse events as required
Additional Notes (optional)
Date of Completion
*
-
Month
-
Day
Year
Date
Completed By (Name)
*
Role or Title
I confirm that all applicable REMS compliance tasks have been completed to the best of my knowledge.
*
I acknowledge and confirm
Submit Checklist
Should be Empty: