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* 1. Date of report

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* 2. Person reporting shortage

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* 3. Hospital/Clinic reporting shortage

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* 4. What medication/medical device are you reporting? (Please include the trade name, formulation of the medication and pack size/volume/concentration or dose, etc.)

If a new shortage please fill in questions 5-7; if a shortage has resolved then please fill in question 8.

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* 5. If difficulty accessing, is this difficulty getting the medication from:

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* 6. Is this a temporary or permanent shortage? (If temporary, please state expected length if known)

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* 7. What is/are the indication/s for which this medication/medical device is intended to be used?

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* 8. Any other information about the shortage or failure to supply?

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* 9. When did the medication/medical device shortage stop?

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* 10. Any other information you wish to give?

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* 11. Approximately how many times per year do you normally prescribe/use this medicine/medical device?

Thank you for completing the survey.

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