This form will be used when the P&T committee wants to circulate some information about a certain formulary change or update. The form is part of the main policy “Pharmacy formulary system policy” and this attachment serves as an example of the form, make sure to change the header and footer to better suit your organization design style, and add the proper dates of creation, modification and due to review date.
| HOSPITAL NAME – PHARMACY AND THERAPEUTICS COMMITTEE FORMULARY UPDATES |
|---|
| Information related to the updated drug |
| Generic name: Brand name: Dosage form: Strength: Manufacturer: Clinical pharmacological class: |
| Committee decision: (highlight one) 1) Primarily approved. 2) Disapproved. 3) Delete. |
| Type of restriction (if any): ……………………………………………………………………………….. |
P&T committee chairperson:
Signature / stamp:
Date:
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