Application for an amendment to an existing drug in the Sunderland Joint Formulary
This form is for general drug amendments to the formulary. These may include:
- Changing position of existing formulary drugs due to new clinical or safety evidence
- Removal of a drug due to new clinical or safety evidence
- Any other existing formulary drug change
Requests must be made by a consultant, general practitioner, or other appropriate senior professional, e.g. CCGmedicines optimisation pharmacist, dentist, optician, senior dietician and non-medical prescribers.
Please note that the applicant or an appropriate deputy (with the expertise to present and discuss the application) MUST attend the JFC meeting in order to present the application. The application will be deferred if there is no appropriate person in attendance.
To ensure that requests are processed as quickly as possible, please return completed forms as soon as possible before the meeting.
The closing date for receipt of requests is currently TWO WEEKS prior to the meeting.
Requests received after this time will normally be deferred to the next meeting.
Application for an amendment to a drug in the Sunderland Joint FormularyDETAILS OF PRODUCT
Generic name:
Brand name:
Dosage form and strength:
INDICATIONS
Is this anUnlicensed drug or
Unlicensed indication / YES NO / If yes, please give rationale for use
Licensed indication for this drug:
(See Summary of Product Characteristics (SPC) via the electronic Medicines Compendium (eMC))
Indication for which the drug is requested:
SUGGESTED AMENDMENT INFORMATION AND EVIDENCE
In which section of the Sunderland Joint Formulary is this medicine currently placed?
(Please state chapter and section)Suggested amendment to the formulary:
Summary of Evidence In Support Of Amendment
(Meta-analyses, systematic reviews, double-blind randomised controlled trials in peer reviewed journals etc. Ensure that evidence to support the amendment suggestion is included (if appropriate))
References - All references or relevant web links MUST be attached or emailed separately
Please include links or references of any appropriate sections from any relevant local or national guidelines e.g. NICE for the suggested amendment.
Evidence on cost effectiveness?
Please provide information on any relevant cost effectiveness information that may result from this suggested amendment.
CLINICAL AND FINANCIAL SUPPORT/AUTHORISATION FOR APPLICATION
Secondary care applicants should seek support/authorisation from the relevant clinical director and business manager prior to submitting the application to the Joint Formulary Committee.
Primary care applicants should seek support/authorisation from the SCCG Prescribing Lead or Chief Pharmacist before submitting the application to the Joint Formulary Committee.
Clinical / I support the request from a clinical perspective. Yes No
Financial / I agree that the Directorate will cover funding for this application (secondary care)
I agree that SCCG will cover funding for this application (primary care)
CHS CLINICAL DIRECTOR/ SCCG GP PRESCRIBING LEAD
Name:
Signature / Date:
CHS DIRECTORATE MANAGER/ SCCG CHIEF PHARMACIST
Name:
Signature / Date:
CHS DIRECTORATE FINANCE MANAGER/ SCCG CHIEF FINANCE OFFICER
Name:
Signature / Date:
APPLICANT DETAILS
Name:
Specialty: / Directorate:
Address for correspondence:
Confirmation of attendance at the Joint Formulary Committee meeting. / I will attend the Joint Formulary Committee meeting on
…………………………………………………[INSERT DATE] to present the application.
DECLARATION OF INTERESTS
Please declare any relevant association with the drug or company concerned. If none, please state NONE.
Examples include funding from drug company for research or attending conferences; involvement in any clinical trial; personal involvement with the drug company (shareholder).
Signature: / Date:
PLEASE ATTACH ANY RELEVANT SUPPORTING INFORMATION AND ENSURE THAT THE RELEVANT SECTIONS ARE SIGNED AND DATED
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