The purpose of this form is to collect information that will assist in the quick delivery of Ciprofloxacin (Cipro) and/or Doxycycline (Doxy) medications that will be made available for yourself and your household contact members during a bioterrorism attack (e.g. anthrax) or a large-scale public health emergency.
Staff member is defined as any Virtua staff member, or contractor permanently assigned at a Virtua facility. Household contacts are defined as anyone the staff member identifies as being in need of early medication to allow the staff member to perform their duties at Virtua. A household contact can be authorized to sign for and pick up medications intended for distibution to staff and household contacts; they must be 18 years of age or older and have a valid form of ID.
Be sure to complete the following information, and keep your records up to date. For each household contact member you will be asked if they can take cipro, doxy, both or neither. If you do not know the answer please contact your physician. You will be asked if the household contact member is under 18, if so, please have their birth date available. Birth dates are necessary to insure the proper amount of medication is distributed (i.e., infants and children).
Questions regarding this medication distribution plan might be answered in our FAQs page.
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