Drug Repository Destruction Record

Scan each item's barcode to auto-fill drug name, strength, NDC, lot, and expiration, matching Wisconsin DHS Form F-62645C (Wis. Admin. Code § DHS 148.11(2)).

Scan each item's barcode to auto-fill drug name, strength, NDC, lot, and expiration. Enter quantity for each item, fill in the destruction details once, sign, then generate the printable record. Nothing you enter here is uploaded — the generated record is yours to print or save as a PDF.

Pharmacy / Facility Information

Name – Pharmacy or Medical Facility

Street Address

City

State

Zip Code

Name – Person Destroying Drugs / Supplies

Date Destroyed

Scan Items

Hold the phone a few inches away so the barcode fills most of the frame

Drug / Medical Supply Information

Enter the number of individual units destroyed (tablets, capsules, mL, patches, etc.) and pick a unit — not the number of bottles/packages.

No items scanned yet

Signature

Date Signed

Signature – Person Destroying Drugs or Medical Supplies

Not signed