Bicillin Distribution Tracking Form

Bicillin Distribution Tracking Form

OHA is required to track the distribution of STD Program Bicillin. We will be unable to continue the Bicillin Access Program if we cannot track distribution through this program.

Please complete this form when you distribute Bicillin to community clinics and providers.

Distribution Date*

How many syringes of Bicillin did you distribute to this clinic/provider?*

Lot Number (s)*

Expiration Date(s)*

Clinic/Provider who received Bicillin*

Address (Street, City, State, Zip)*

If you know the Orpheus case number(s), please include here:

If the individual(s) being treated is/are known, are they pregnant?

Yes

No

Unknown

Your Name*

LPHA*

Email*

Phone*

Comments or questions?

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