Medicines reconciliation, allergy and insulin audit

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Number of beds occupied on ward

1. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

2. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

3. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

4. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

5. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

6. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

7. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

8. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

9. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

10. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

11. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

12. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

13. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

14. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

15. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

16. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

17. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

18. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

19. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

20. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

21. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

22. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

23. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

24. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

25. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

26. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

27. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

28. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

29. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

30. Patient initials

• Medicines reconciliation completed within (hours)

  24

  48

  72

  72+

Number of unintentional/undocumented changes/omissions/additions detected?

• Allergy status already documented prior to pharmacy visit?

  Yes

  No

  N/A

• Allergy status checked and confirmed by pharmacy?

  Yes

  No

  N/A

Insulin

• Subcutaneous insulin prescribed? If yes for each insulin fill in below

  Yes

  No

Insulin 1

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 2

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A

Insulin 3

• Are units written in full?

  Yes

  No

  N/A

• Is the dose clear and legible?

  Yes

  No

  N/A