Wisconsin household pharmaceutical collection site registration (Form 4430-030)

Household pharmaceutical collection program information

As of July 1, 2015, Wisconsin law requires persons who collect unused medications from households to register their collection sites with the Wisconsin Department of Natural Resources.

Items marked with an asterisk (*) are required.

NOTICE: This form is authorized by s. 165.65(5)(d), Wis. Stats. Completion of this form is required, except where stated on the form or in the instructions. Personally identifiable information will be used for program
administration and must be made available to requesters as required by Wisconsin Open Records law [s. 19.3119.39,
Wis. Stats].

Question Title

* Collection program operator (organization/agency/community name):

Question Title

* Please indicate whether your collection program accepts the following items:

	Yes	No
Controlled substance medications	Controlled substance medications Yes	Controlled substance medications No
Noncontrolled prescription medications	Noncontrolled prescription medications Yes	Noncontrolled prescription medications No
Over-the-counter medications	Over-the-counter medications Yes	Over-the-counter medications No
Creams	Creams Yes	Creams No
Liquids	Liquids Yes	Liquids No
Aerosol cans	Aerosol cans Yes	Aerosol cans No
Low-pressure inhalers	Low-pressure inhalers Yes	Low-pressure inhalers No
Items with liquid mercury (e.g., thermometers, blood pressure devices)	Items with liquid mercury (e.g., thermometers, blood pressure devices) Yes	Items with liquid mercury (e.g., thermometers, blood pressure devices) No
Medication bottles or containers	Medication bottles or containers Yes	Medication bottles or containers No
Devices used to administer drugs (e.g., tubing or syringes)	Devices used to administer drugs (e.g., tubing or syringes) Yes	Devices used to administer drugs (e.g., tubing or syringes) No

Question Title

* Do any of the following packaging instructions apply to your program? (check all that apply)

Bring items in original prescription bottle (mark over patient's name and address, but retain drug name and dose) or original over-the-counter container.

Remove pills from packaging.

Put items in one-quart (or smaller) plastic bag.

Put sharps in a container meeting standards in the state medical waste rule (s. NR 526.07).

Put sharps in a container meeting a standard more stringent than the state medical waste rule.

Other (please specify)

Question Title

* Collection program operator (organization/agency/community name):

Question Title

* Please indicate whether your collection program accepts the following items:

Question Title

* Do any of the following packaging instructions apply to your program? (check all that apply)

Question Title

* Website where the public can get information about your collection program: