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Giving chief executive information about particular diversion-risk medicines - s233 MPMR

Section 233 of the Medicines and Poisons (Medicines) Regulation 2021 (MPMR) requires a pharmacist to give notice to the chief executive in the approved form if the amount of a diversion-risk medicine being sought, other than a diversion-risk medicine that is also a monitored medicine,  exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal.

This form must be used by the pharmacist to give notice to the chief executive unless the pharmacist has a reasonable excuse.

You may be contacted by an inspector appointed under the Medicines and Poisons Act 2019 or an authorised delegate of the chief executive to require further information and/or for auditing/inspection purposes relevant to this notice.

If, at this stage, you are not able to provide all the information in this notice, under section 233 of the MPMR you must give as much information as possible and you can provide any additional information or a follow-up notice at a later date.

Contact information

This notice is managed by Medicines Compliance.
Should you require assistance in completing this form,please email MedicinesCompliance@health.qld.gov.au

Privacy notice

Personal information collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. Queensland Health is collecting your personal information on this approved form under authority of section 233 of the MPMR. All personal information will be securely stored and only accessible by Queensland Health staff. Your personal information will not be disclosed to other third parties without consent,unless the disclosure is authorised or required by under law. Failure to provide information may render the form incomplete, which may constitute an offence under the Medicines and Poisons Act 2019. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at http://www.health.qld.gov.au/global/privacy

Required fields are marked with an asterisk (*).
Please indicate if this is the initial notice or follow-up notice *
Please email additional information to MedicinesCompliance@health.qld.gov.au and include the initial notice Submission ID in the email title.
Please provide details of pharmacist giving the notice
Business / organisation details
Is the contact number different to the one you provided earlier? *
Is the email address different to the one you provided earlier? *
Section 233 (MPMR)
I am giving notice under section 233 of the MPMR that *
Why do you reasonably suspect the amount of the particular diversion-risk medicine being sought exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal? *
Did you dispense all/any of the particular diversion-risk medicines? *
Did you keep a copy of the prescription?
Please include details of the particular diversion-risk medicine/s that were dispensed/not dispensed?
Note:: Schedule 2, Part 3 of the MPMR provides a list of diversion-risk medicines. This form only relates to diversion-risk medicines that are NOT monitored medicines.
Information: Diversion-risk medicine/s should be listed using only the terms used in the Australian Standard of Uniform Scheduling of Medicines and Poisons (SUSMP/Poisons Standard). These terms do not include brand names of products, they only refer to active ingredients. If a substance is not listed in the SUSMP/Poisons Standard but is a derivative of one that is listed in the SUSMP, then select the substance that is listed.

Diversion-risk Medicine
Unit description
Strength
Strength unit
Total number of units

Please provide details of the prescriber?
Did you contact the prescriber to discuss that the amount of the particular diversion-risk medicine being sought exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal?
Please insert date you contacted the prescriber
What was the outcome when you contacted the prescriber?
Please complete s228 notice – reporting and preventing use of unlawful document or s 230 reporting supply on false prescription or purchase order (whichever relevant)
Please complete s228 notice – reporting and preventing use of unlawful document or s 230 reporting supply on false prescription or purchase order (whichever relevant)
Is there any supporting evidence available to confirm that the amount of a diversion-risk medicine being sought exceeds the amount or frequency of doses that the person could reasonably be seeking for the therapeutic treatment of the person or the person’s animal?
Indicate all items that may apply
Certification *

MPMR-233, Version 1

Last updated: 20 October 2021