AXIS-FRM-SQM.

01-015
KUALIFIKASI PELANGGAN FASYANFAR

Nama Relasi : Tanggal Kunjungan :

Alamat Lengkap : Jam Kunjungan :
Cabang AAM :
Hasil kunjungan :
1. Apakah terdapat praktek dokter di sarana relasi? Jika ya, pastikan jumlah dokter yang praktek & jadwal prakteknya
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2. Apakah terdapat RS / Klinik / Praktek dokter / Lab yang alokasinya berdekatan dengan sarana relasi?
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3. Berapa jumlah resep Psikotropika & Reguler yang masuk ke sarana per hari?
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4. Bagaimana kondisi daerah sekitar sarana :
 Apakah ada pemukiman?
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 Apakah ada perkantoran?
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 Apakah sarana melayani layanan antar obat ke pasien / customer?
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5. Apakah dokumen perizinan sarana kesehatan masih up date dan sesuai antara alamat pada dokumen perizinan dengan
fisik dilapangan?
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6. Bagaimana hari dan jam operasional sarana kesehatan?
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7. Apakah pemilik sarana memiliki sarana kesehatan lainnya? Jika ya, sebutkan nama sarana beserta alamat pelengkapnya
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8. Apakah sarana kesehatan memiliki Apoteker Pendamping atau Tenaga Teknis Kefarmasian (TTK)?
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9. Bagaimana jam kerja / shift kerja APJ, APING & TTK di sarana kesehatan tersebut?
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Verifikasi Hasil Kunjungan Relasi oleh Apoteker AAM :

(Jelaskan apakah hasil kunjungan ke sarana kesehatan relasi sesuai dengan kewajaran jumlah & Frekuensi Order Relasi selama ini)
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Yang melakukan kunjungan: Kacab AAM Paraf / TTD & Stempel Relasi:

( ) ( ) ( )

No. Dokumen: AXIS-FRM-SQM.01-015 Tanggal Efektif: 4 Juli 2022

No. Rev.: 03
 AXIS-FRM-SQM.01-015
KUALIFIKASI PELANGGAN PBF / PBAK

Nama Relasi : Tanggal Kunjungan :

Alamat Lengkap : Jam Kunjungan :
Cabang AAM :
Hasil kunjungan :
1. Apakah dokumen perizinan dan sertifikat CDOB PBF masih up date dan sesuai antara alamat pada dokumen perizinan
dengan fisik dilapangan? *)
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2. Apakah dokumen perizinan PBAK masih up date dan sesuai antara alamat pada dokumen perizinan dengan fisik
dilapangan? **)
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3. Apakah terdapat kerjasama tender dengan sarana lainnya terkait pengadaan obat dan/atau alat kesehatan? Jika ya,
pastikan nama & jumlah sarana yang dimaksud beserta
kontrak .....................................................................................................................................................................................
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4. Berapa jumlah Surat Pesanan Psikotropika, Prekursor, OOT & Reguler yang masuk ke PBF per hari? *)
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5. Berapa jumlah Surat Pesanan Alat Kesehatan yang masuk ke PBAK per hari? **)
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6. Apakah PBF/PBAK hanya menyalurkan produk kepada relasi yang berwenang sesuai peraturan?
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7. Apakah ada lonjakan pemesanan selama 3 bulan terakhir dari PBF / PBAK tersebut? Jika ya, pastikan alasan dan dokumen
pendukung tersedia (jika
ada) .............................................................................................................................................................................................
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8. Bagaimana hari dan jam operasional PBF / PBAK?
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9. Apakah pemilik PBF / PBAK memiliki PBF / PBAK lebih dari satu atau sarana kesehatan lainnya? Jika ya, sebutkan nama
sarana beserta alamat pelengkapnya
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10. Apakah PBF / PBAK memiliki Apoteker Pendamping atau Tenaga Teknis Kefarmasian (TTK)?
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11. Bagaimana jam kerja / shift kerja APJ, Apoteker lain (jika ada) & TTK (jika ada) di PBF / PBAK tersebut?
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Note:
*) : Khusus untuk PBF
**) : Khusus untuk PBAK

Verifikasi Hasil Kunjungan Relasi oleh Apoteker AAM :

(Jelaskan apakah hasil kunjungan ke PBF / PBAK sesuai dengan kewajaran jumlah & Frekuensi Order Relasi selama ini)
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Yang melakukan kunjungan: Kacab AAM Paraf / TTD & Stempel Relasi:

( ) ( ) ( )

No. Dokumen: AXIS-FRM-SQM.01-015 Tanggal Efektif: 4 Juli 2022

No. Rev.: 03