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Part 1 Annual Declaration (for use by Dental Practitioners) Please complete and return the form below by 20th March 2009: This questionnaire relates to activities within the last 12 months and relates to controlled drugs (CDs) in schedules (Sch) 2 and 3 only. Your Name

Please indicate which applies to you: Address of organisation

NHS Dental Practitioner  Private Dental Practitioner  PCT employed Practitioner  Locum Dental Practitioner 

(or main place of work to which this declaration relates) Please list on a separate sheet any other premises to which this declaration may apply)

Area of activity Q1 Q2 Q3 Q4 Q5


Do you prescribe CDs? Do you supply / dispense CDs from stock or a doctor’s bag? Do you administer CDs (or supervise or assist patients’ own administration)? (i) Do you hold stock CDs either on the premises or off site? (ii) Do you hold patients’ CDs (in storage or whilst awaiting disposal)? Do you destroy or dispose of CDs (patient returns/stock)?

If you have answered yes to any of the above questions, please also complete part 2 of the declaration (attached) Declaration: i) I declare, to the best of my knowledge and belief, that I do not handle, use, prescribe or manage Schedule 2 or 3 CDs on any premises from which I provide medical services; Or


I declare that to the best of my knowledge and belief that I do/do not comply (please delete as appropriate) with the provisions of the Misuse of Drugs Act 1971 and the associated Regulations in its handling, use, prescribing and management of Schedule 2 and 3 CDs.


Registration No


Date Signed

Please note that you must notify us of any material changes to the answers to Q1 – Q5 above within 14 days of the change – this is a statutory requirement. Please return your completed declaration / self assessment to: Neill McDonald, Controlled Drugs Accountable Officer, (Assistant Director of Medicines Management), NHS Kirklees, Princess Royal Community Health Centre, Greenhead Road, Huddersfield, HD1 4EW

NHS Kirklees – Controlled Drugs Statutory Declaration for Dental Practitioners – revised February 2009