ISLE OF WIGHT NHS

NEW DRUGS APPLICATION FORM

PROPOSAL FORM FOR A NEW DRUG / NEW USE FOR A DRUG TO BE CONSIDERED BY THE DIRECTORATE /PRIMARY CARE PRESCRIBING COMMITTEE (PCPC)/ FOR APPROVAL BY DRUGS ADVISORY COMMITTEE (DAC) FOR INCLUSION ON TO THE FORMULARY/EXTENDED FORMULARY LIMITATIONS

TO BE COMPLETED BY THE REQUESTOR

This form should be completed in full and submitted, preferably with references supporting the application, to the Directorate Pharmacist or Chief Pharmacist, Pharmacy Department, St. Mary's Hospital. For Primary Care, submissions should go to the Primary Care medicines management lead pharmacist.

In order for the drug to be considered for formulary inclusion the requestor must have the support of the Directorate Management Board or Primary Care Prescribing Committee (PCPC) before the application can be considered by the Drugs Advisory Committee (DAC)

Requestor: ...... Drug/preparation:......

Do you consider the drug should become available to:

All prescribers Consultants only

Named Departments/Speciality Other (please specify)

Reason for request:

Perceived advantage(s) over currently available therapies:

Perceived place of this drug within the present treatment schedule:

The requestor should attach draft Guidelines indicating specifically when the drug/preparation would be used with respect to drugs already on the formulary and other treatments.

In order to estimate the probable cost of introducing this preparation, please indicate:

a. Amount required to treat ONE patient for ONE month (or ONE course, if less):......

b. Number of patients likely to be treated each year: ......

If approved, the request should be forwarded to Clinical Directors and Hospital Medical Staffing Committee (HMSC) for information and the requestor should then liaise with the Clinical Standards Group on production of definitive guidelines.

If there are Primary Care implications or the cost cannot be contained within Directorate funding, the request must be

forwarded to Gillian Honeywell, DAC Secretary, Pharmacy Department.

References submitted with this request (minimum of 2):

1.

2.

3.

Statement of support from IW NHS Consultants, and/or G.Ps:

Name / Signature: …………………………………………………………

Name / Signature: …………………………………………………………

Name / Signature: …………………………………………………………

Signature of requestor: ......

Clinical Director ……………………………………………….

Date: ......

NB: This form will be returned to you unless all parts are fully completed.

Declaration of interest

Is the manufacturer or supplier of the drug providing or proposing to supply any of the following:

1. Educational support (in addition to product information) YesNo

2. Sponsorship to conferences or symposia Yes No

3. Equipment, services or finance YesNo

Have you, or anyone in your speciality, at any time been involved in any clinical trial

involving the proposed drug Yes No

Has a drug company assisted in the production of this application?YesNo

If the answer is yes to any of these questions please supply details, where possible, on a separate sheet.

Further clarification may be sought to allow full consideration by the Drugs Advisory Committee

K:\DAC\Intranet documents\New Drugs Application Form.doc

10/20/2018