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نموذج طلب إضافة أو حذف دواء للمرشد الطبي العلاجي الوطني

This document is a form requesting the addition or deletion of a drug from the Jordan National Drug Formulary. It requires information such as the generic and trade names of the drug, manufacturer, dosage form, strength, intended use, alternatives in the formulary, and cost analysis. The form must then be approved by the organization's Pharmacy and Therapeutic Committee, the JNDF Specialty Technical Committee, and finally the National Pharmacy and Therapeutic Committee before a decision is made to approve or deny the request.

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Samer Khallad
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219 views4 pages

نموذج طلب إضافة أو حذف دواء للمرشد الطبي العلاجي الوطني

This document is a form requesting the addition or deletion of a drug from the Jordan National Drug Formulary. It requires information such as the generic and trade names of the drug, manufacturer, dosage form, strength, intended use, alternatives in the formulary, and cost analysis. The form must then be approved by the organization's Pharmacy and Therapeutic Committee, the JNDF Specialty Technical Committee, and finally the National Pharmacy and Therapeutic Committee before a decision is made to approve or deny the request.

Uploaded by

Samer Khallad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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‫(قائمة األدوية الرشيدة) نموذج طلب إضافة أو حذف دواء للمرشد الطبي العالجي الوطني‬

Jordan National Drug Formulary Addition / Deletion Request Form

Addition Deletion

No. :

Date:

Important:-

All information requested on this form must be filled out completely and referenced by published
scientific articles or textbooks or it will be returned to requesting Healthcare Professional Pharmaceutical
Company promotional literature is not acceptable. No action will be taken on forms that are submitted
incomplete.
1 Generic Name:

2 Trade Name(s):

3 Manufacturer(s):

4 Dosage form(s) :

5 Strength :

6 Dosage schedule & Estimated duration of therapy:

7 Specific pharmacological actions or uses which justify the need for the preparations:

8 Therapeutic use(s) :
(Intended indications for this drug must be approved by one of the respected drug regulatory
agencies such as FDA or EMEA).

9 Are there any alternative drugs in the formulary?


10 How is this drug superior to the existing current formulary drugs in terms of Indications:

Therapeutic efficacy:

Safety:

Compliance :

11 Economic Analysis:
Drug cost for an entire course of therapy (JFDA public price)

12 If this drug is admitted to the formulary, the following drug(s) should be deleted:

13 Should this drug be restricted (Drug Class) to use by certain specialty of the medical staff? If
so, to whom and Why?

14 What will be the anticipated annual use rate if this drug is added to the drug formulary?

15 List specific independent literature references (evidence-based ) :

16 Requested by:

Specialty:

Signature and Date:


17 Attachments:

18 Head of Specialty Remarks:

Signature, Name and Date:

‫قرار لجنة الصيدلة والمداواة العليا للمؤسسة‬


Organization Pharmacy and Therapeutic Committee

Request:
Approved Yes Denied
Reason:

Decision By Majority:
Signatures and Names:
PTC Chairperson PTC Secretary

Date:

‫قرار اللجنة الفنية صاحبه االختصاص للمرشد العالجي الوطني‬


JNDF Specialty Technical Committee

Request:
Approved Yes Denied
Reason:

Decision By Majority:
Signatures and Names:
PTC Chairperson PTC Secretary

Date:

‫قرار لجنة الصيدلة والمداواة الوطنية‬


National Pharmacy and Therapeutic Committee

Request:
Approved Yes Denied
Reason:

Decision By Majority:

NPTC Chairperson NPTC Secretary

Signature Signature

Date Date
NPTC Members Names who DID VOTE AGAINST the decision if any:

NPTC Members Names who DID NOT VOTE for the decision if any:

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