HazardousDrugRisk)Acknowledgement) NameofEmployee: )
[Pages:1]Hazardous
Drug
Risk
Acknowledgement
Name
of
Employee:
__________________________________
I
understand
working
with
or
near
hazardous
drugs
in
health
care
settings
may
cause
skin
rashes,
infertility,
miscarriage,
birth
defects,
and
possibly
leukemia
or
other
cancers.
I
understand
that
Sample
Pharmacy
maintains
detailed
policies
and
procedures
on
the
proper
storage,
handling,
transport
and
disposal
of
hazardous
drugs.
Sample
Pharmacy
has
put
in
place
a
variety
of
administrative,
engineering
and
work
practice
controls
to
reduce
the
risk
of
occupational
exposure
to
hazardous
drugs.
I
understand
Sample
Pharmacy's
policies
and
procedures
will
be
reviewed
and/or
amended
on
an
annual
basis
and
the
policies
and
procedures
seek
to
reflect
information,
standards
and
regulations
from
relevant
local,
state
and
federal
regulatory
bodies
as
well
as
practice
standards
from
professional
associations.
I
have
been
provided
with
didactic
training
that
reflects
the
policies
and
procedures
on
hazardous
drugs
and
have
been
afforded
the
opportunity
to
ask
questions.
After
completion
of
the
training
I
have
been
required
to
take
and
successfully
pass
written
testing.
I
have
also
had
my
hazardous
drug
handling
techniques
observed
and
documented
on
Sample
Pharmacy's
Hazardous
Drug
Competency
Form.
Review
of
hazardous
drug
information
and
competency
evaluation
will
occur
annually.
I
received
and
successfully
completed
this
training
before
performing
any
activity
associated
with
hazardous
drugs.
I
understand
Sample
Pharmacy's
polices
and
procedures
and
agree
to
comply
with
them
at
all
times.
I
also
agree
that
I
will
immediately
seek
out
the
Pharmacy
Manager
or
my
direct
supervisor
should
a
question
occur
during
work
activities.
I
acknowledge
that
failure
to
follow
the
established
policies
and
procedures
may
put
me
at
risk
of
exposure
to
hazardous
substances
which
can
lead
to
acute
effects
such
as
skin
rashes;
chronic
effects,
including
adverse
reproductive
events
such
as
infertility,
miscarriage,
or
birth
defects;
and
possibly
the
development
of
cancer.
________________________________________
_______________
Signature
of
Employee
Name
above
Date
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