Drug Repository Donation Record

Scan each item's barcode to auto-fill drug name, strength, NDC, lot, and expiration, matching Wisconsin DHS Form F-62645B (Wis. Admin. Code §§ DHS 148.06(2)(a)1, (b)3).

Scan each item's barcode to auto-fill drug name, strength, NDC, lot, and expiration. Enter the quantity and unit (tablets, mL, etc.) donated for each item, fill in donor and recipient details once, sign, then generate the printable record or send it directly. Donor name and address are never saved to this device — they exist only in memory until you generate/send the record or leave the page, and clear automatically after a few minutes of inactivity. Donor info is transmitted off this device only if you tap “Send to St. Vincent de Paul Pharmacy”, and only to the recipient organization's own Cognito Forms account — this app does not store it anywhere.

What Can Be Donated

Per Wis. Admin. Code § DHS 148.06, a drug or medical supply is eligible only if it meets all of the following:

  • In its original, unopened, tamper-evident packaging that shows the lot number and expiration date (unopened single-unit-dose packaging is also acceptable)
  • Expiration date is at least 90 days after the donation date
  • Not adulterated or misbranded
  • Accompanied by this signed donation record

Not eligible, regardless of the above:

  • Controlled substances (Wis. Stat. § 961.01(4))
  • Drugs requiring FDA patient-registry enrollment (21 U.S.C. § 355-1(f)(3)(F))
  • Opened, expired, or otherwise adulterated/misbranded items

See the DHS Drug Repository Program consumer guide for full program details.

Donor Information

Donor info clears automatically after 5 minutes of inactivity

Recipient Information

Which barcode do I scan?

Most medicine packages have two different barcodes. Only one of them works with this scanner.

✅ Square barcode (2D) — scan this one. It has the lot number and expiration date built in, so scanning it fills those in for you.

0 51234 56789 4

❌ Long barcode (linear) — not this one. It usually only identifies the product itself, not the lot number or expiration date, so scanning it won't fill those in.

Tip: look on the box or bottle near the printed lot number and expiration date — the square barcode is usually right next to that text.

Drug / Medical Supply Information

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

No items scanned yet
Hold the phone a few inches away so the barcode fills most of the frame

Signature

No signature (optional)