Expenditure Disclosure Form

APRN Expenditure Disclosure Form

EXPENDITURE DISCLOSURE FORM FOR MANUFACTURERS SUBJECT TO THE PROVISIONS OF CONNECTICUT GENERAL STATUTES 21a-70f

Effective 6/27/2022 - Manufacturers who have submitted the information required by this statute to the federally equivalent program will satisfy the statute's requirements outlined in 21a-70f. Please submit and maintain a record of the submission to the federal program and proof that the request was completed. The federal requirements can be found here.

APRNs Practicing Not in Collaboration with a Licensed Physician

Report Submissions Reports are due by July 1st every year

APRN Payment Report Form(Excel)

Please submit the form in an .xlsx or .csv format. Each Advanced Practice Register Nurse should have a single line in the spreadsheet for each manufacturer. The total amount of compensation provided should be placed in the "Total Value of Payment to APRN" field and the minimum threshold for reporting is the same as the federal requirement. No further explanation is required regarding the types of compensation provided.

This file should be emailed to DCP.DrugManufacturers@ct.gov with a subject of "APRN Payment Report". An auto-response will be sent to the email address of the submitter which is proof of your submission. The Department will contact you if we have any questions about your submission.

Questions concerning this form should be submitted to DCP.DrugManufacturers@ct.gov. Please note that you will receive an auto-response from that email box every time that you submit an email which is your confirmation that we received your email.