The state health officer may prescribe on a statewide basis a self-administered hormonal contraceptive by one or more standing orders in accordance with a protocol consistent with the United States Medical Eligibility Criteria for Contraceptive Use (MEC) Centers for Disease Control and Prevention, that requires:

1. (1) Use of the self-screening risk assessment questionnaire described below;
2. (2) Written and oral education;
3. (3) The timeline for renewing and updating the standing order;
4. (4) Who is eligible to utilize the standing order;

5. (5) The pharmacist to make and retain a record of each person to whom the self-administered hormonal contraceptive is dispensed, including:

   1. (A) The name of the person;
   2. (B) The drug dispensed; and
   3. (C) Other relevant information.