Sei sulla pagina 1di 1

Republic of the Philippines

Department of Health
METRO MANILA CENTER FOR HEALTH DEVELOPMENT

EXPIRED MEDICINES REPORT FORM

NAME OF HEALTH FACILITY: __________________________________ DATE OF REPORTING: __________________

PROGRAM NAME OF MEDICINE DOSE BATCH/ LOT NUMBER EXPIRATION DATE QUANTITY

Prepared by: (Accountable Person) Noted by: ( Physician – in - Charge)

_________________________________________________________ __________________________________________________________
NAME & SIGNATURE / DATE NAME & SIGNATURE / DATE
Acknowledge by: (Supply Officer) Acknowledge by: (DOH Pharmacist)

_________________________________________________________ __________________________________________________________
NAME & SIGNATURE / DATE NAME & SIGNATURE / DATE