| S-100 |
Background Check |
Waiver for KBI/FBI background check and instructions for Fingerprint Card |
| S-150 |
Personal History |
For individual applications with offense, disciplinary or criminal history |
| S-200 |
Continuing Education |
For pharmacists submitting continuing education records as part of reinstatement or other application |
| S-300 |
Disciplinary History |
For facilities reporting disciplinary history |
| S-310 |
Partnership Ownership |
For facilities owned by a partnership or limited partnership |
| S-320 |
LLC Ownership |
For facilities owned by an LLC |
| S-330 |
Corporate Ownership |
For facilities owned by a public, private or nonprofit corporation |
| S-340 |
$25,000 Surety Bond Form |
$25,000 surety bond form for wholesale distributors |
| S-345 |
$100,000 Surety Bond Form |
$100,000 surety bond form for wholesale distributors |
| S-350 |
Non-Resident Supplement |
For non-resident pharmacies, distributors, nonprescription drug distributors and DME |
| S-400 |
Intern Experience Hours |
Log and preceptor certification for pharmacy intern experience hours |
| S-500 |
Kansas Hospital Electronic Supervision Form |
For hospitals receiving remote supervision |
| K-10 |
Notice of Exemption from K-TRACS (PMP) Reporting |
For pharmacies that do not dispense controlled substances |
| N-100 |
Automated Drug Delivery System Notice: Installation or Removal |
For a pharmacy, located and registered in Kansas, that will have an automated drug delivery system located in that pharmacy, institutional drug room or medical care facility
For LTCF Automation, see BA-21
|
| N-400 |
Unused Medication Participation Form: Donating Entity |
For medical care facilities, mail order pharmacies and adult care homes intending to participate in the Utilization of Unused Medications program by donating medications |
| N-450 |
Unused Medication Participation Form: Clinics & Qualifying Centers |
For clinics and qualifying centers intending to participate in the Utilization of Unused Medications program by accepting medications |