Drug Repository Transfer Record

Scan each item's barcode to auto-fill drug name, strength, NDC, lot, and expiration, matching Wisconsin DHS Form F-62645A (Wis. Admin. Code § DHS 148.09(3)).

Use this form when a pharmacy or medical facility distributes donated drugs or medical supplies to a participating repository. Scan each item's barcode to auto-fill drug name, strength, NDC, lot, and expiration. Enter the quantity and unit transferred for each item, fill in the transferring and receiving facility details, indicate whether the whole or part of the original donation is being transferred, sign, then generate the printable record. Everything stays on this device — nothing is submitted anywhere.

Transferring Pharmacy or Medical Facility

Name – Pharmacy or Medical Facility

Date of Transfer

Street Address

City

State

Zip Code

Receiving Pharmacy or Medical Facility

Name – Pharmacy or Medical Facility

Date of Receipt

Street Address

City

State

Zip Code

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.

❌ 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.

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

No items scanned yet

Transfer Scope

The entire original donation is being transferred. The original donation form is attached to this transfer record. The original donation is being partially transferred. A copy of the original donation form is attached to this transfer record.

Signature

Name – Representative (Print or type)

Date Signed

Signature – Representative

Not signed