Are you an independent contractor or a small business owner in the United States? If so, then you may have heard of the VA Form 10-9012 that must be submitted when registering with the U.S. Department of Veterans Affairs (VA). This form is an important document and understanding it helps to ensure that all your registration information is accurate and up-to-date. By having an applicant's acceptable identification verified, this form allows veterans and their eligible dependents to gain access to proper mental health care. In this blog post, we'll discuss how to complete the VA Form 10-9012 as well as what additional information needs to be included with it in order for your registration process to successful.
| Question | Answer |
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| Form Name | Va Form 10 9012 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | responsible investigational 12b form, va 10 9012, 9012 form, drug information record |
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INVESTIGATIONAL DRUG INFORMATION RECORD |
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1. TITLE OF STUDY |
6. SOURCE OF DRUG (If other than manufacturer or sponsor) |
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2. RESPONSIBLE INVESTIGATOR (Individual who signed Form |
7. THERAPEUTIC CLASSIFICATION AND EXPECTED THERAPEUTIC |
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EFFECT(S) |
3.PRINCIPAL INVESTIGATOR (If different than responsible investigator)
4.ALL DESIGNATIONS FOR DRUG (Generic and chemical, code,
8. DOSAGE FORMS AND STRENGTHS
9A. IS THIS DRUG A CONTROLLED SUBSTANCE?
YES |
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NO (If "Yes," complete Item 9B) |
5. MANUFACTURER OR OTHER SPONSOR |
9B. CLASSIFICATION |
10.STABILITY AND STORAGE REQUIREMENTS
A.PRIOR TO MIXING, STORAGE SHOULD BE (Check applicable box(es))
AT ROOM TEMPERATURE
IN REFRIGERATOR
IN FREEZER
PROTECTED FROM LIGHT
OTHER (Specify)
B. AFTER MIXING, DRUG REMAINS STABLE IN REFRIGERATOR FOR (Check appropriate box and enter quantity)
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MINUTES |
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HOURS |
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DAYS |
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11. DRUG ADMINISTRATION PROCEDURES |
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A. ROUTES OF ADMINISTRATION |
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B. ADMINISTRATION DIRECTIONS |
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C. RECONSTITUTION DIRECTIONS |
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(Check appropriate box(es)) |
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ORAL |
I.V. INFUSION |
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I.V.PUSH |
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12A. DRUG ADMINISTERED BY (Also complete Item 12B) |
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12B. ROUTE |
13. USUAL DOSAGE RANGE |
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A. PHYSICIAN ONLY |
B. PROFESSIONAL NURSE |
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14. KNOWN SIDE EFFECTS AND TOXICITIES
I5A. DOUBLE BLIND? |
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15B. NAME OF INDIVIDUAL WHO HAS CODE DESIGNA- |
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15C. TELEPHONE NUMBERS |
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TION |
DAYTIME |
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EVENING |
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(If "YES" complete |
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YES |
NO |
Items 15B and 15C) |
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16.SPECIAL PRECAUTIONS (Include drug interactions (synergisms, antagonisms), contraindications, etc.)
17. ANTIDOTE
18.STATUS (Check one)
INVESTIGATIONAL
PHASE I
PHASE II PHASE III
COMMERCIALLY AVAILABLE 0THER (Specify)
19. NAMES OF AUTHORIZED PRESCRIBERS
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B. |
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C. |
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D. |
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20. SIGNATURE OF RESPONSIBLE OR PRINCIPAL INVESTIGATOR |
DATE |
22. PATIENT IDENTIFICATION (I.D. plate or give name - last, first, middle |
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21.APPROVED BY
A.SUBCOMMITTEE ON HUMAN STUDIES
21A. SIGNATURE OF CHAIRPERSON |
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DATE |
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B. RESEARCH AND DEVELOPMENT COMMITTEE |
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21B. SIGNATURE OF CHAIRPERSON |
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DATE |
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VA FORM |
SUPERSEDES EXISTING STOCK OF VA FORM |
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NOV 1989 |
WILL BE USED. |
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