Vendor Name (required) Vendor's Legal Name System Name (required) Name of the system for the title of the Certification Report System Identifier (required) The Subsystem identifier uniquely defines the implementation of the subsystem such as a version or model number Description (required) Brief Description of the system under test Functional Description (required) Details functional description including inputs, outputs, input interface description, output interface description, physical and logical boundaries, and security boundaries of the system. * If an application provider has multiple versions of the application, all of which use the same code and controls for the functions that DEA is requiring, a single audit may be able to address multiple versions if other changes could not impact these functions. The following will determine which requirements of the DEA's interim final rule will be audited for compliance. Is the application system to be certified for a filling or pharmacy system? yesno *If yes, please answer the following: Does the system have or support central fill options? yesno Does the system dispense gamma-hydroxybutyric acid under a prescription? yesno Will the system be used to prescribe Schedule II level prescriptions? yesno Will the system be used to prescribe Schedule III and IV level prescriptions? yesno Will the system be used to prescribe Schedule V level prescriptions? yesno Does the system support a written record of an emergency oral prescription? yesno Does the application digitally sign prescription records upon receipt? yesno Does the system support partial fill of prescriptions? yesno Does the system support prescribing for a Schedule III, IV, or V narcotic drug approved by the FDA specifically for "detoxification treatment" or "maintenance treatment"? yesno Does the pharmacy compound? yesno *Please list any additional information about the system that might be useful for iBeta to establish a proposal Δ
