State Of Utah Class A Retail Self Inspection
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6State of Utah
Department of Commerce
CLASS A RETAIL
SELF
Division of Occupational and Professional Licensing
160 E 300 S
Telephone : (801) 530-6628
INSPECTION
P.O. Box 146741
Toll Free in Utah: (866) 275-3675
Salt Lake City, UT 84114-6741
Website:
Email: DOPLInvestigations@utah.gov
INSTRUCTIONS
This self-inspection form is provided with the intent to improve the ability of DOPL to regulate the pharmacy profession within the
State of Utah. It is also intended to aid you, as a pharmacist, to examine your practice and ensure that it is in conformance with
Utah State laws and rules. However, please do not use this inspection form as a substitute for familiarizing yourself with current
regulations, as it is not intended to be all-inclusive as far as Utah law is concerned. This form may be filled out by pharmacy staff,
but it must be reviewed and signed by the Pharmacist-in-Charge.
Note that EMAIL is the preferred method of submission. Please do not fax. To submit by email, please download and fill out the
file using Adobe Acrobat or Adobe Reader, then save the file to your desktop or documents and attach it to an email addressed to
DOPLInvestigations@utah.gov. Alternatively, you may fill the form out electronically, or by hand, then scan the document to a file
and send via email. If those options are not available please fill out the form electronically and print it out, or print and fill it out by
hand, and then mail to the following address:
DOPL Bureau of Investigation
160 E 300 S
P.O. Box 146741
Salt Lake City, UT 84114-6741
Please read the self-inspection questionnaire thoroughly. All fields should be filled, and all statements should have a
response. Enter all date fields in a (mm/dd/yy) format. For items #1-47, ALL “No” answers must be accompanied by an
explanation on the last page. For items #48-49, ALL “Yes” answers must be accompanied by an explanation on the last
page.
INFORMATION
Pharmacy Name:
Date: _______________
Pharmacy License #:
Expiration: _______________
Controlled Substance License #:
Expiration: _______________
DEA Registration #:
Expiration: _______________
Pharmacy FEIN #:
Pharmacy Email:
Pharmacy Telephone:
Fax:
Pharmacy Hours:
Mon - Fri:
Saturday:
Sunday:
Pharmacy Street Address:
City:
State:
Zip:
Pharmacist In Charge:
Pharmacist In Charge License #:
Expiration:
PERSONNEL
List ALL pharmacists, interns, and pharmacy technicians (attach a separate sheet, if necessary):
Name:
License #:
Expiration:
Name:
License #:
Expiration:
Name:
License #:
Expiration:
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