[ Instructions]
Thank you for responding to our invitation to participate in a survey about your pharmacy’s inventory of
prescription products. The information you provide will remain confidential, and your identity and the identity of
your pharmacy will not be revealed to anybody outside of DMD.
Please fill out the questionnaire carefully. Tally your inventory and usage for only the product strength and
package sizes listed and specify full and partial bottles or packages (i.e. 1 ½, ¼ etc.). If you have no inventory
of a particular product you can leave the line blank.
Helpful Inventory Reporting Tips
• Restasis: Report the number of trays, not vials
o 45 vials of a 30 Count Tray of Restasis = 1.5 Trays
• PEGASYS: Report the number of SYRINGES or PENs not boxes
o 1 box of Pegasys 180 mcg/mL syringes = 4 syringes
Thank you for your continued participation in our research studies.
ID:________________ Name:_________________ Phone #:______________ State: _____ Page 1 of 2
*****Please complete this survey at your pharmacy******
#2009 September Retail PIP Please complete ALL of this form and FAX toll free to 1-800-846-INFO(4636) or
1-800-469-4363 by Monday, September 24, 2012 or sooner if possible.
Please report on NDCs listed below.
Capsule and Tablet Inventory
b.)# Units Sold
Past 30 Days
(i.e. ⅓, 1 ⅛ , 2 ⅖)
CARAFATE (Aptalis)
58914-0171-10
1g Tablet/ Bottle of 100
1
a.) Inventory Data
Include partial units
(i.e. ¼, ⅓, ½)
#Bottles
PYLERA (Aptalis)
58914-0600-21
140-125-125mg Caps/Bottle of 120
2
#Bottles
#Bottles
TRICOR
00074-6122-90
48mg Tablet/Bottle of 90
3
#Bottles
#Bottles
(Abbott)
00074-6123-90
145mg Tablet/Bottle of 90
4
#Bottles
#Bottles
TRILIPIX
00074-9642-90
45mg Tablet/ Bottle of 90
5
#Bottles
#Bottles
(Abbott)
00074-9189-90
135mg Tablet/Bottle of 90
6
#Bottles
#Bottles
ZENPEP DR
42865-0104-02
Caps 3k-10k-16k/ Bottle of 100
7
#Bottles
#Bottles
(Eurand)
42865-0100-02
Caps 5k-17k-27k/ Bottle of 100
8
#Bottles
#Bottles
42865-0101-02
Caps 10k-34k-55k/ Bottle of 100
9
#Bottles
#Bottles
42865-0102-02
Caps 15k-51k-82k/ Bottle of 100
10
#Bottles
#Bottles
42865-0103-02
Caps 20k-68k-109k/ Bottle of 100
11
#Bottles
#Bottles
42865-0105-02
Caps 25k-85k-136k/ Bottle of 100
12
#Bottles
#Bottles
00004-0038-22
450mgTablet/Bottle of 60
13
#Bottles
#Bottles
Product
(manufacturer)
VALCYTE (Roche)
NDC #
Form/Strength/Pkg Size
#Bottles
Other Formulation Inventory
Product
(manufacturer)
NDC #
Form/Strength/Pkg Size
a.) Inventory Data
Include partial units
(i.e. ¼, ⅓, ½)
b.)# Units Sold
Past 30 Days
(i.e. ⅓, 1 ⅛ , 2 ⅖)
CARAFATE (Aptalis)
CANASA
58914-0170-14
Oral Solution 1g/10ml/Bottle of 420ml
14
#Bottles
#Bottles
58914-0501-56
1,000 Mg Suppository/ Box of 30
15
#Boxes
#Boxes
(Aptalis)
58914-0501-42
1,000 Mg Suppository/ Box of 42
16
#Boxes
#Boxes
PEGASYS
00004-0350-09
180 mcg per 1 mL solution single use vial
17
#Vials
#Vials
(Genentech)
00004-0352-39
180 mcg/0.5 mL/Kit of 4 w/alcohol swabs
18
#Syringes
#Syringes
00004-0357-30
180 mcg/0.5 mL/Pack of 4
19
#Syringes
#Syringes
135 mcg/0.5 mL Autoinjector/Pack of 4
20
#Pens
#Pens
PEGASYS PROCLICK
00004-0360-30
00004-0365-30
180 mcg/0.5 mL Autoinjector/Pack of 4
21
#Pens
#Pens
RECTIV (Aptalis)
42747-0235-30
0.4% Ointment/ 30g Tube
22
#Tubes
#Tubes
RESTASIS
00023-9163-30
0.4 mL Dropperette Vials/Tray of 30
23
#Trays
#Trays
0.4 mL Dropperette Vials/Tray of 60
24
#Trays
#Trays
#Tubes
#Tubes
#Bottles
#Bottles
(Allergan)
00023-9163-60
TESTIM (Auxilium)
66887-0001-05
50 mg/5 gram Gel/Box of 30
25
VALCYTE (Roche)
00004-0039-09
50mg/mL Solution
26
Please continue to page 2
ID:________________ Name:_________________ Phone #:______________ State: _____ Page 2 of 2
#2009 September 2012 PIP
Please carefully read what is being requested in columns a, b, c & d for each NDC
Inventory & Expiration Date
a.) Invt
Data
Product
(manufacturer)
ULTRASE
(Aptalis)
b.)# Units
Sold
Past 30
Days
Include
partial units
(i.e. ¼,1 ⅓,)
(i.e. ⅓, 2 ⅖)
#Btls
NDC #
Form/Strength/Pkg Size
58914-0045-10
250mg Tab (4.5K-25K-20K)
/Bottle of 100
27
#Btls
27__
28__
58914-0002-10
223mg Tab (12K-39K-39K)/
Bottle of 100
28
#Btls
#Btls
ULTRASE MT 18
58914-0018-10
333mg Tab (18K-58.5K58.5K)/ Bottle of 100
29
#Btls
#Btls
ULTRASE MT 20
58914-0004-10
371mg Tab (20K-65K-65K)/
Bottle of 100
30
#Btls
#Btls
ULTRASE MT 20
58914-0004-50
371mgTab (20K-65K-65K)/
Bottle of 500
31
#Btls
#Btls
58914-0785-10
250mg Tablets/
Bottle of 100
32
#Btls
#Btls
58914-0785-50
250mg Tablets/
Bottle of 500
33
#Btls
#Btls
58914-0790-10
500mg Tablets/
Bottle of 100
34
#Btls
#Btls
58914-0111-10
468mg Tab (8K-30K-30K)/
Bottle of 100
35
#Btls
#Btls
58914-0116-10
935mg Tab (16K-60K-60K)/
Bottle of 100
36
#Btls
#Btls
(Aptalis)
URSO FORTE
(Aptalis)
VIOKASE
(Aptalis)
d.) List
bottle
exp. date
(mm/yy)
27__
ULTRASE MT 12
URSO
c.) # of
btls per
exp. date
28__
29__
29__
30__
30__
31__
31__
32__
32__
33__
33__
34_
34_
35_
35__
36_
36__
General Stocking Questions
Please check your shelf to see if you currently stock the following new products.
DO NOT LEAVE ANY OF THESE BLANK.
37
38
39
40
41
42
43
Amyvid
Combivent Respimat
Dymista
Elelyso
Forfivo XL
Intermezzo
Korlym
1
1
1
1
Yes
2
Yes
2
Yes
2
No
No
No
Yes
2
1
Yes
2
No
1
Yes
2
No
Yes
2
1
No
No
44
45
46
47
48
49
50
Myrbetriq
Pertzye
Stendra
Stribild
Subsys
Tudorza Pressair
Zioptan
1
1
1
1
Yes
2
No
Yes
2
No
Yes
2
No
No
Yes
2
1
Yes
2
No
1
Yes
2
No
Yes
2
No
1
51. What is the date you filled out this questionnaire? September _______, 2012
PLEASE FAX TO: 1-800-846-4636 (INFO) OR 1-800-469-4363 by September 24, 2012