Appendix B

Vaccination and Training Status of Pharmacy Staff (NSE104)

Please keep this record up to date at all times

Name of all pharmacy staff (Including pharmacist managers, regular locums and pre-registration pharmacists) / Date of
Hep B vaccinations
(If refused, staff please sign and date) / A ‘suitably trained staff’ is defined as an individual who has completed all three of these
Date read protocol, guidelines and service agreement / Date completed CPPE pack / Date briefed by PCT Medicines Management Team Member

Note: This record is to be kept in the pharmacy. However, a member of the Nottingham Crime and Drugs Partnership may request to see it for professional audit purposes

Appendix C

Needle & Syringe Exchange Registration form (NSE101)

Client Initials / Date of Birth
Postcode / Gender / Male □ Female □
Registration Date / City Resident? / Yes □ No □
Ethnicity
Religion
Disability
Sexuality
Currently in Treatment? / Yes □ No □ / If yes, where?
What drugs are you currently using? (list all including alcohol)
FOR PHARMACY USE ONLY
Tick list for:
Harm reduction advice given e.g. over dose, safer injecting, BBV advice
Referral to specialist needle exchange
Referral to treatment provider (record who)
Parenting pack given

Appendix D

Confidentiality policy

1)A confidentiality form (see below) must be completed with all clients at registration and the confidentiality policy explained to them. Information about clients must not to be given to anybody without the client’s permission. This includes the police, the client’s relatives and their GP (Note: Disclosure of information is only allowed under certain circumstances as specified in the confidentiality agreement).

2)If the pharmacist feels that they need to break a client’s confidentiality (due to child protection concerns or the client presenting a serious risk of harm to themselves or others), they should contact the Health Shop specialist needle exchange service for advice and support.

3)If a pharmacist or member of pharmacy staff is found to have breached a client’s confidentiality without good cause, the contract with Nottingham Crime and Drugs Partnership may be terminated immediately.

4)For any other queries regarding clients, the pharmacy should contact the Mark Garner at the Crime and Drugs Partnership on Tel 0115 8765712.

Confidentiality agreement and service user contract

This pharmacy will provide a confidential* needle exchange service that is non judgmental, supportive and respectful to your needs.

You have the right to be treated without fear of discrimination on any grounds.

*Confidential means that any information that you give us will not be passed on to any one else (this includes family, friends, GP’s, other services / agencies etc) unless you either give us your permission.

However there may be exceptions to this when we may have to pass on information without your permission. This will include situations such as:

  • If you give us information about a serious offence (such as murder or violence)
  • If you tell us about someone who is being physically or sexually abused
  • If you make us aware of a child or young person who is at risk of abuse or harm
  • If there is a serious risk of death or harm to you or another person
  • If you or someone else is posing a terrorist threat
  • If you become ill or lose consciousness on the premises as we may need to provide basic information to the ambulance service
  • We are instructed to by a Court of Law

Staff will treat you with respect and expect the same treatment from you. Abuse of any kind, including physical or verbal will not be tolerated and could result in you being excluded from using the service in the future.

I understand the above and agree to abide by the terms of this agreement:

Service user signature…………………………………………….. Date ………

Worker’s signature…………………………………………………. Date ……..

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Appendix FNeedle & Syringe Exchange Scheme Record Sheet (NSE102)

Issuing details / Number of each syringe pack issued / Boxes of WFI issued / Number of ascorbic acid sachets issued / Number of sharps bins returned / Estimated number of syringes returned
Date / Sex / Initials / DOB / Postcode / 1 Red / 2 Blue / 3 Green / 4 Orange / 5 Sports
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Totals
Total number of syringe packs issued

When estimating the contents of sharps bins returned, 1 bin contains approximately 10 used works.

N.B. At each transaction always offer water for injection (WFI). Encourage the return of sharps bins.

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Appendix G

Pharmacy Needle Exchange Quarterly Claim Form (NSE105)

Pharmacy Address

Quarter / Period / Retainer Fee Claimed * / Submission Deadline
Quarter 1 / April to June 2014 / £485 / 5th July 2014
Quarter 2 / July to September 2014 / 5th October 2014
Quarter 3 / October to December 2014 / 5th January 2015
Quarter 4 / January to March 2015 / 5th April 2015

Please state quarter period claimed for Quarter 1 2 3 4 (delete as applicable)

Products issued

Item / Total number issued
Syringe packs
Water for Injection
Citric Acid
Ascorbic Acid

Total number of transactions =

Total claim for the quarter

* Retainer fee claimed (50% to be claimed at year start and the other 50% once the pharmacy has conducted it’s 500th transaction)
Total transaction fees (£1.50 per transaction)
Total amount claimed
Invoice number: / Date

Ensure all Needle & Syringe Exchange Registration Forms NSE101 and all Needle & Syringe Exchange Record Sheets NSE102 are enclosed

Please e-mail to:

Or post to: The Nottingham Crime and Drugs Partnership, The Shire Hall, High Pavement, Nottingham, NG1 1HN

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