W. Va. Code R. agency 210, tit. 210, ser. 210-01, app A
Prescription Drug Advertising Expenses Reporting Form
Please file your completed Appendix A with:
Governor's Office of Health Enhancement and Lifestyle Planning
Greenbrooke Building, 1124 Smith Street, Room 105
Charleston, West Virginia 25301
| Name of Reporting Entity |
| Reporting Period |
3.2.a. List below the total amount the reporting entity spent for advertising and direct promotion of prescription drugs to consumers, prescribers, pharmacies and patient support or advocacy groups within the State of West Virginia.
| Name of Reporting Entity | Amount Spent |
3.2.b. List below the total number of West Virginia prescribers to whom the reporting entity provided directly or indirectly, gifts, grants or payments of any kind in excess of one hundred dollars ($100.00) for the purpose of advertising prescription drugs.
| Annual Aggregate Amount of fees, food entertainment, recreational activities, travel expenses, gifts, grants or other payments | Total Number of Prescribers |
| $100.00 - $2,500.00 | |
| $2,501.00 - $5,000.00 | |
| $5,001.00 - $7,500.00 | |
| $7,501.00 - $10,000.00 |
3.2.c. List below the direct-to-consumer advertising which is directed at, received by or intended to be received by consumers in this state, the form of the advertising and the total amount expended for advertising.
| Form of Advertising | Total Expenditure on Advertising |
I certify upon information and belief that the information contained on this form is true, correct and complete.
| Signature: |
| Printed Name: |
| Title: |
| Date: |
Taken, sworn and subscribed before me, this ______ day of __________________, 20_____,
by _________________________________________________________________________.
| Notary signature |
| Commission expires |
Seal:
W. Va. Code R. agency 210, tit. 210, ser. 210-01, app A