NPTC Feedback Form for Scheduled Meeting Topics

The purpose of this form is to collect feedback and/or recommendations regarding scheduled agenda topics for upcoming National Pharmacy and Therapeutics Committee meetings from Indian Health Service (IHS) clinicians working at Federal, Tribal or Urban Indian Organization programs/sites/facilities. Input on topics for upcoming review can include potential medications for addition or deletion from the IHS National Core Formulary (NCF). *This form IS NOT INTENDED to serve as a formulary request for individual patients, hospitals, or clinics. Fields marked with a red '*' are required fields and must be filled out to submit a request.

**Requests from Pharmaceutical and/or other Industry representatives will not be honored.

Your email address (Required)*

Please enter your email address below to verify your affiliation with an IHS Federal, Tribal, or Urban Indian Organization program. Entry of your email address is required to submit a Meeting Topics request and implies your consent for NPTC representatives to contact you via email (only if needed for additional information or clarification). Only responses from clinicians working at IHS Federal, Tribal or Urban Indian Organization programs/sites/facilities will be considered.

Medication name or drug class (Required)*

Please provide information about the scheduled NPTC meeting topic, medication(s), medication class and/or disease state/condition that you would like to be considered during NPTC deliberation.

Indication, disease state, or condition (Optional)

Please provide information about medications, medication indication(s), disease state(s) or condition(s) that you would like to see reviewed by the NPTC in the future.

Reason for request (Required)*

Please provide information about medications, medication indication(s), disease state(s) or condition(s) that you would like to see reviewed by the NPTC in the future.

Select

Please provide further information (Optional)

Please provide a brief summary of any additional information pertinent to this request that may help prioritize the need for review at an upcoming NPTC meetings

Send me a copy of my responses

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