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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F62643 (02/2022) STATE OF WISCONSIN DRUG REPOSITORY PROGRAM NOTICE OF PARTICIPATION OR WITHDRAWAL Completion of this form meets the notification
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How to fill out drug take-back and disposal

01
To fill out a drug take-back and disposal form, follow these steps:
02
Start by gathering all the expired or unused medications you wish to dispose of.
03
Check with your local pharmacy or healthcare provider if they have a drug take-back program. If they do, ask for a drug take-back form.
04
Fill out the form with your personal details, including your name, contact information, and any relevant medical information.
05
List the medications you are disposing of on the form, including their names, strengths, and quantities.
06
If there are any controlled substances among the medications, make sure to mark them clearly on the form.
07
Carefully review the form to ensure all the information is accurate and complete.
08
Once the form is filled out, follow the instructions provided by the pharmacy or healthcare provider on how to submit the form and safely dispose of the medications.
09
If there is no drug take-back program available in your area, consult your local waste management or environmental services for guidance on how to properly dispose of medications.
10
Remember to always follow the recommended guidelines and regulations for safe disposal of medications to protect the environment and prevent misuse.

Who needs drug take-back and disposal?

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Drug take-back and disposal is beneficial for the following individuals:
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- Patients who have expired or unused medications that they no longer need.
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- Individuals who have finished their prescribed medications and have leftover doses.
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- Caregivers responsible for managing medications for patients who have passed away or are no longer able to take their medications.
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- Healthcare facilities, pharmacies, and other healthcare providers that need to dispose of expired or unused medications.
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- Communities and society as a whole, as proper disposal of medications helps prevent drug misuse, accidental ingestion, and environmental contamination.

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Drug take-back and disposal refers to programs and processes that allow individuals to safely return unused, expired, or unwanted medications for proper disposal to reduce the risk of misuse and environmental harm.
Health care providers, pharmacies, and other entities that participate in drug take-back programs are typically required to file drug take-back and disposal reports.
To fill out drug take-back and disposal forms, individuals must provide details regarding the quantities and types of medications being returned, along with relevant dates and contact information as specified by the regulatory bodies overseeing the program.
The purpose of drug take-back and disposal is to promote public health and safety by minimizing the chances of drug abuse, preventing accidental poisoning, and reducing harmful environmental impacts from improper drug disposal.
Information that must be reported includes the types and quantities of drugs collected, the location of the take-back operation, the dates of collection, and the method of disposal used.
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