Prescription Stock Shortage Survey
Report prescription stock shortages, affected items, urgency, operational impact, and follow-up details for inventory review.
Shortage Details
Pharmacy or Site Name
*
Location or Branch
*
Report Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Person Name
*
Contact Email or Phone
*
Affected Prescription Stock
Medication Name(s) or SKU
*
Dosage Form / Strength
*
Current Quantity on Hand
*
Estimated Days of Stock Remaining
*
Shortage Severity
*
Low
Moderate
High
Critical
Impact and Follow-up
Reason for Shortage
*
Please Select
Supplier Delay
Increased Demand
Backorder
Delivery Issue
Inventory Discrepancy
Unknown
Other
Impact on Patient Fulfillment or Operations
*
Low Impact
1
2
3
4
5
6
7
8
9
High Impact
10
1 is Low Impact, 10 is High Impact
Expected Restock Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Actions Already Taken
Contacted Supplier
Checked Warehouse Stock
Requested Transfer from Another Location
Updated Inventory Records
Informed Prescribers or Staff
Planned Alternative Fulfillment
Other
Additional Notes
Submit Survey
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