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].

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

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

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

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

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