Building A Csib Binder

BUILDING YOUR CSIB
BINDER
Copyright © 2015 John Wiley & Sons, Inc. All rights reserved.
FORMS INCLUDED
• DD1348
• NAVMED 6710/5 (BULK STOCK)
• NAVSUP 1250
• NAVMED 6710/5 (WORKING STOCK)
• DD1289
• DD200
• NAVMED 6710/22
• NAVMED 6710/23
RECEIVE MEDICATION VIA DD1348
TO SHOW
RECIEPT,
HAVE THE
BULK STOCK
CUSTODIAN BSC SIGN HERE DATE
(BSC) SIGN MUST HAVE

FULL NAME, RANK,
THE 1348 AND TITLE
(BULK STOCK CUSTODIAN)
1348 GO BY FROM SOP
CREATE NAVMED 6710/5 FOR BULK STOCK
BULK STOCK NSN: MFG:

LOT #:
EXP DATE:
1- ADD BULK STOCK TO TOP LEFT

CORNER USS YOUR LAST NAME NAME OF DRUG MG/ML BT/PG
2- ADD NSN TO THE MIDDLE 20
3- ADD MFG, LOT #, EXP DATE TO
TOP RIGHT HAND CORNER
4- ACTIVITY = NAME OF YOUR
SHIP
5- NAME OF DRUG = MATCHS THE
DD1348
6- STRENGTH = STRENGTH OF
MEDICATION
7- UNIT = PACKAGE OR BOTTLE
FOR BULK STOCK , MUST MATCH
DD1348
8- ADD THE TWO DIGIT YEAR TO
THE DATE BLOCK
**ALL INFORMATION MUST MATCH

DD1348** Copyright © 2015 John Wiley & Sons, Inc. All rights reserved.
BULK STOCK NSN: MFG:
LOT #:
EXP DATE:
6505-01-098-5802 HOSPIRA
IDC98765
OCT 2022
DIAZEPAM TABLETS 5MG PG
FIRST LINE ENTRY
20 JUL EXPL12345
BULK
STOCK ------ 01 ZERO 01 BSC
INITIALS
*********NOTE************
ONLY THIS INFORMATION MAYBE TYPED
ALL ENTRIES AFTER THE FIRST LINE MUST
BE HANDWRITTEN
BSC SIGN HERE 21 JUL 20

REQUEST A TRANSFER FROM BULK STOCK TO WORKING STOCK VIA
NAVSUP1250
Copyright © 2015 John Wiley & Sons, Inc. All rights reserved. 13.1 - 9
REQUEST A TRANSFER FROM BULK STOCK TO WORKING STOCK VIA
NAVSUP1250
20 JUL BULK STOCK ONE T001

DIAZEPAM TABLETS
BULK STOCK CUSTODIAN

ONE PACKAGE OF DIAZEPAM TABLETS WAS TRANSFERRED FROM BULK TO WORKING STOCK
(ONE PACKAGE EQUALS 100 TABLETS, MRF: HOSPIRA; LOT #: IDC98765; EXP DATE OCT 2022) WORKING STOCK CUSTODIAN
A COPY OF THIS FORM IS REQUIRED IN BOTH THE

BULK AND WORKING STOCK LOGS 13.1 - 10
DOCUMENTATION ON THE BS 6710/5
20 JUL T001 WORKING

STOCK
------ ZERO 01 ZERO
BSC
INITIALS
CREATE NAVMED 6710/5 FOR WORKING
STOCK
WORKING STOCK NSN: MFG:
LOT #:
EXP DATE:
1- ADD WORKING STOCK TO TOP

LEFT CORNER USS YOUR LAST NAME NAME OF DRUG MG/ML TAB/SYR
2- ADD NSN TO THE MIDDLE 20
3- ADD MFG, LOT #, EXP DATE TO
TOP RIGHT HAND CORNER
4- ACTIVITY = NAME OF YOUR
SHIP
5- NAME OF DRUG = MATCHS THE
DD1348
6- STRENGTH = STRENGTH OF
MEDICATION
7- UNIT = INDIVDUAL TABLETS OR
SYRINGES
8- ADD THE TWO DIGIT YEAR TO

THE DATE BLOCK
**ALL INFORMATION MUST MATCH

NAVSUP 1250** Copyright © 2015 John Wiley & Sons, Inc. All rights reserved.
FIRST LINE ENTRY
20 JUL T001
WORKING
STOCK
------ 100 ZERO 100
WSC
INITIALS
*********NOTE************
ONLY THIS INFORMATION MAY BE
TYPED ALL ENTRIES AFTER THE
FIRST LINE MUST
BE HANDWRITTEN
RX EXAMPLE FROM SOP
INSCRIPTION: DRUG NAMES

AND CONCENTRATION
SUBSCRIPTION: INSTRUCTION
TO PERSON FILLING RX (I.E.
DISPENSE 4 TABS)
SIGNA: DIRECTIONS FOR

THE PATIENT ON HOW TO
TAKE MEDS
DD1289
PATIENT INFORMATION AS PER
THE SOP; ALSO INCLUDE DODID
JANE SUE DOE ALLERGIES:

BE GOOD PROVIDERS, ADD ALLERGIES
31 OCT 1987
DODID: 1234567890 CO SIGNATURE:
SUPPLY/S2 INSCRIPTION SUBSCRIPTION SIGNA
BERTHING 2/RACK 12
NUMBER OF TABLETS OR SYRINGES
22 JUL 2020 NEEDING TO BE ISSUES
USS YOUR LAST NAME
NR = NO REFILLS, YOU ARE NOT
AUTHORIZED TO WRITE FOR REFILLS
DIAZEPAM, 5MG TABLETS QUALITY ASSURANCE DATA FOR THE MED

YOU ARE PRESCRIBING /
DISPENSE 8 TABLETS YOU WILL PUT YOUR NAME DOWN AS THE
FILLED BY SINCE YOU ARE THE WSC
SIGNA: TAKE TWO TABLETS
BY MOUTH EVERY SIX HOURS
RX NUMBER MUST INCLUDE A RED
“C”, THEN THE 2 DIGIT YEAR, THEN
IF MED IS LEFT IN SYR USE THIS THE NEXT NUMBER IN
SPACE TO DOCUMENT HOW YOU #8 CHRONOLOGICAL ORDER FOR THE
DISPENSED THE REMAINING MED NR CALENDAR YEAR
HOSPIRA OCT 2022 FULL NAME OF THE PERSON WRITING
IDC98765 YOUR NAME THE RX, RANK, NPI NUMBER (USE YOUR
YOUR FULL NAME LAST 4 FOR NOW)
C20-001 RANK, NPI NUMBER
CO SIGNATURE REQUIRED FOR ALL CONTROLLED
SUBSTANCES PRESCRIBED BY AN IDC
BACK OF 1289
I HAVE RECEIVED
________ TABS/CAPS OF
_____________________.
PATIENT NAME:
DOB:
CONTACT INFO:
ADDRESS:
BERTHING/RACK:
PHONE:
_________________________
PATIENT SIGNATURE
TO SHOW A MEDICATION HAS BEEN DISPENSED
TO SHOW A RX HAS BEEN DISPENSED, THE
PERSON FILLING THE RX WILL DRAW A
DIAGONAL LINE ACROSS THE FRONT
20
L20
THEY WILL THEN WRITE ON THE LINE
JU
“DISPENSED (INSERT NUMBER OF
TABLETS OR SYRINGES) ON (INSERT
22 DATE) ON THE TOP OF THE LINE
ON
ES
THE PERSON FILLING THE RX WILL

THEN WRITE “FILLED BY:” BELOW
BL
THE LINE AND WILL SIGN THEIR

BY TA
NAME
ED HT
:
LL IG
FI D E
SE
EN
SP
DI
NOTE: THE TEXT IS ONLY IN

RED SO IT IS MORE VISABLE,
YOU WILL USE BLACK INK
TO DOCUMENT DD1298 ON WORKING STOCK INVENTORY
22 JUL C20-001 JANE DOE ----- 92 WSC

ZERO 8
1234567890 INITIALS
DESTROY MEDICATION VIA DD200
THIS IS USED TO ACCOUNT FILL OUT THE BLOCKS THAT ARE
FOR THE DESTRUCTION OF SURROUNDED BY RED IN THE
ALL CONTROLLED CSIB SOP
SUBSTANCES; IF IT IS ONE
TABLET OR AN ENTIRE BOX
IN THIS SCENARIO WE WILL SAY
THE SHIP TOOK A SHARP TURN
WE WILL BREAK IT UP INTO
WHILE HMC OAKES DISPENSED
TWO SECTIONS TO REVIEW
THE DIAZEPAM TABLETS FOR JANE
THE PROPER WAY TO FILL THIS
DOE. 4 TABLETS ROLLED OFF THE
FORM OUT.
COUNTER AND FELL INTO A PILE
DUST.
DATE THE ALPHA-NUMERIC

DD200 WAS CODE THAT WILL
CREATED. MATCH THE 6710/5
AND SERVE AS A
SERIAL NUMBER.
MUST MATCH (CAN NOT MATCH
6710/5 AND ANY OTHER # IN
AMAL THE PROGRAM)
20200722 D20-001 NA
MUST MATCH MUST BE EXACT,
6710/5 AND IF FROM WS IT IS
6505-01-098-5802 DIAZEPAM TABLETS 04 0.07 0.28
AMAL TABS/SYR, IF FROM
BS IT WILL BE IN
EXPLANATION 4 TABLETS FELL INTO PILE OF DIRT WHEN THE SHIP TOOK A SHARP TURN AND A PG/BT
OF REASON FOR PRESCRIPTION WAS BEING FILLED. WORKING STOCK CUSTODIAN HAS REQUESTED
DESTRUCTION DESTRUCTION DUE TO CONTAMINATION. UNIT COST IS $ PER
REQUEST TAB/SYR OR PG/BT
DEPENDING ON
DETAILED INFO CONTAMINATED TABLETS DISOLVED IN A BOWL OF WATER AND SOLUTION WAS FLUSHED LOCATION. $$ IS
ON METHOD OF DOWN CHT SYSTEM IN THE MEDICAL HEAD. CSIB MEMBERS VERIFIED ALL LIQUID DISPOSED LISTED ON DD1348.
DESTRUCTION, OF. LOT#: IDC98765 EXP DATE: OCT2022. CSIB MEMBER ________ CSIB MEMBER_____________ IF IN TABS/SYR,
INCLUDING QA TOTAL COST WILL
DATA, AND BE DIVIDED BY
SIGNATURE AREA TOTAL NUMBER IN
FOR CSIB PACKAGE.
MEMBERS
TOTAL COST PER BOTTLE: 6.59 MULTIPLY
TOTAL TABS PER BOTTLE: 100 QUANTITY BY
UNIT COST TO
COST PER TAB: $0.07 FIND TOTAL COST
DESTROY MEDICATION VIA DD200 PART 2
FILLED OUT BY PERSON
REQUESTING DESTRUCTION.
EITHER THE BULK OR WORKING OAKES, ELISABETH E
STOCK CUSTODIAN.
22 JUL 2020
WILL BE THE SENIOR MEDICAL

OFFICER IS ONE PRESENT.
WILL BE THE SUPPLY OFFICER ON

CRUISER/DESTROYERS AND SUPPO, IAM
PLATFORMS WITHOUT A
22 JUL 2020
MEDICAL OFFCER
WILL BE THE EXECUTIVE

OFFICER
OFFICER, EXECUTIVE
22 JUL 2020
WILL BE THE COMMANDING

OFFICER
COMMANDING, OFFICER
22 JUL 2020
DOCUMENTATION OF DD200
22 JUL D20-001 DD200 ------- ZERO 4 88 WSC
CONTROLLED SUBSTANCE INVENTORY REPORT
COVERSHEET
BLOCK 1: SHIP NAME
BLOCK 2: BULK OR WORKING STOCK. SEPERATE
NAVMED 6710/22 & NAVMED 6710/23 ARE
REQUIRED FOR BULK AND WORKING STOCKS
BLOCK 3: DAY INVENTORY STARTED
BLOCK 4: DAY INVENTORY FINISHED (SHOULD BE THE SAME)
COMMANDING OFFICER SIGNATURE IS REQUIRED
WILL BE EITHER BULK OR WORKING STOCK CUSTODIAN

DEPENDING ON WHICH INVENTORY IS BEING CONDUCTED
SUPPLY OFFICER = THE SUPPLY OFFICER
CSIB MEMBERS: NAMES OF THE MEMBERS WHO CONDUCTED

THE INVENTORY. SENIOR MEMBER IS
LOCATED AT THE TOP
AUDIT SHEET
SHIP NAME WORKING STOCK
USS YOUR LAST NAME
BULK OR WORKING STOCK

DIAZEPAM TAB ZERO 100 12 88
NAME MUST MATCH 6710/5. QA
DATA IS NOT REQUIRED
BUT HIGHLY ENCOURAGED.
UNIT OF ISSUE NEEDS TO MATCH THE SAFE

IT IS COMING FROM: WORKING STOCK = TAB/SYR
BULK STOCK = PG/BT
INFORMATION MAY BE TYPED
PHYSICAL COUNT MUST BE HANDWRITTEN
MEMBERS CONDUCTING THE BOARD
DOCUMENTING A CSIB AUDIT
CSIB SENIOR
22JUL
AUDIT
-------- -------- -------- -------- 88
CSIB INT

Building A Csib Binder

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Building A Csib Binder

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BUILDING YOUR CSIB

(BSC) SIGN MUST HAVE

BULK STOCK NSN: MFG:

1- ADD BULK STOCK TO TOP LEFT

**ALL INFORMATION MUST MATCH

DIAZEPAM TABLETS 5MG PG

BSC SIGN HERE 21 JUL 20

20 JUL BULK STOCK ONE T001

BULK STOCK CUSTODIAN

A COPY OF THIS FORM IS REQUIRED IN BOTH THE

20 JUL T001 WORKING

1- ADD WORKING STOCK TO TOP

8- ADD THE TWO DIGIT YEAR TO

**ALL INFORMATION MUST MATCH

INSCRIPTION: DRUG NAMES

SIGNA: DIRECTIONS FOR

JANE SUE DOE ALLERGIES:

DIAZEPAM, 5MG TABLETS QUALITY ASSURANCE DATA FOR THE MED

THE PERSON FILLING THE RX WILL

THE LINE AND WILL SIGN THEIR

NOTE: THE TEXT IS ONLY IN

22 JUL C20-001 JANE DOE ----- 92 WSC

DATE THE ALPHA-NUMERIC

WILL BE THE SENIOR MEDICAL

WILL BE THE SUPPLY OFFICER ON

WILL BE THE EXECUTIVE

WILL BE THE COMMANDING

22 JUL D20-001 DD200 ------- ZERO 4 88 WSC

BLOCK 3: DAY INVENTORY STARTED

BLOCK 4: DAY INVENTORY FINISHED (SHOULD BE THE SAME)

COMMANDING OFFICER SIGNATURE IS REQUIRED

WILL BE EITHER BULK OR WORKING STOCK CUSTODIAN

SUPPLY OFFICER = THE SUPPLY OFFICER

CSIB MEMBERS: NAMES OF THE MEMBERS WHO CONDUCTED

BULK OR WORKING STOCK

UNIT OF ISSUE NEEDS TO MATCH THE SAFE

INFORMATION MAY BE TYPED

PHYSICAL COUNT MUST BE HANDWRITTEN

MEMBERS CONDUCTING THE BOARD

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