Self-Assessment Forms

The assessment shall be performed before July 1 of every odd-numbered year. The self-assessment forms must remain on-site at the facility. Only submit the form to the board if requested by board staff.

The board is in the process of updating some Self-Assessment forms through a formal rulemaking. The updates include references to statutory and regulatory changes that occurred since approval of the currently adopted forms.

Current regulation requires a pharmacy to complete the currently adopted version of the Self-Assessment form. Please be advised, however, the board will accept completion of either the currently adopted version OR the draft version. The draft version is likely to be a more helpful assessment to the pharmacy or wholesaler completing it.

Draft Self-Assessment Forms

• Community Pharmacy / Hospital Outpatient Self-Assessment (17M-13, Rev. 4/25) (PDF)
• Compounding Self-Assessment (17M-39 Rev. 1/2022) (PDF)
• Hospital Pharmacy Self-Assessment (17M-14, Rev. 4/25) (PDF)
• Wholesaler Self-Assessment (17M-26, Rev. 4/25) (PDF)

Current Adopted Self-Assessment Forms

• Automated Drug Delivery Systems (17M-112 Rev. 1/22) (PDF)
• Community Pharmacy / Hospital Outpatient Self-Assessment (17M-13, Rev. 1/22) (PDF)
• Compounding Self-Assessment (17M-39, Rev. 02/12) (PDF)
• Hospital Pharmacy Self-Assessment (17M-14, Rev. 1/22) (PDF)
• Surgical Clinic Self-Assessment (17M118, Rev. 1/24) (PDF)
• Wholesaler Self-Assessment (17M-26, Rev. 1/22) (PDF)