Medication Takeback Locaton Mapping Data

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* 1. Collection Location Name

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* 2. Street Address

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* 3. City

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* 4. State

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* 5. Zip Code

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* 6. Contact Email

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* 7. What does the collection location accept? (select all that apply)

controlled substances

solid medications

liquid medications

sharps/needles

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* 8. Collection Date(s)

Permanent Collection (during regular business hours)

Collection Event (specify date and time if known)

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* 9. Website url