Doh 2340 Form PDF Details

For businesses and professionals handling controlled substances in New York State, understanding and accurately completing the DOH 2340 form is a critical requirement. This form, generated by the New York State Department of Health's Bureau of Narcotic Enforcement, serves as a formal request for approval to dispose of or destroy controlled substances. The detailed instructions embedded within the form ensure that the disposal and destruction process adheres strictly to the designated protocols. These protocols are in place to ensure compliance with federal, state, and local laws, reflecting the serious nature of handling controlled substances. The form not only captures basic request information such as the licensee's name, address, and controlled substance license number but also demands specifics about the disposal process, including the method of disposal, the location, and the personnel involved. Submission of the form should be planned at least two weeks in advance of the proposed disposal date, strictly during weekdays to facilitate oversight by the Bureau. Additionally, it emphasizes the need for the disposal or destruction to occur exactly as proposed, without any deviations unless prior approval is obtained. This rigorous approach underlines the government's commitment to ensuring public safety and preventing the misuse of narcotics by maintaining a stringent control over their disposal and destruction.

QuestionAnswer
Form NameDoh 2340 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdoh 782 form, doh 2340 narcotic disposal fillable form, new york 2340 disposal, doh form 4329

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement

Request for Approval of Disposal/Destruction of Controlled Substances

 

 

 

 

 

 

SECTION I – REQUEST INFORMATION

 

 

 

 

Office Use Only

3 Please use Adobe Acrobat to fill-in fields and save a copy on your computer.

 

LOG

NUMBER

3 Requests should be submitted to the applicable Bureau of Narcotic Enforcement office at

 

Approved

 

 

least 2 weeks prior to the proposed date of disposal/destruction.

 

 

 

 

 

 

 

 

3 Destruction must take place on a week day between 9 a.m. and 3 p.m. No weekends or holidays.

 

Partially Approved

 

3 Email submissions to BNE are preferred to bnedestruction@health.ny.gov

 

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensee Name

 

 

 

 

 

 

 

 

 

 

 

 

Comment(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street*

 

 

 

 

 

 

 

 

*If using a P.O. Box,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a street address must

 

 

 

 

 

 

 

 

 

 

 

 

 

 

be included.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Controlled Substance License #

 

Note: If the facility/program or individual is not subject to Article 33

 

 

 

 

 

 

 

 

 

controlled substance licensure, the applicable DEA registration number

 

 

 

 

 

 

 

 

 

should be entered.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Disposal/Destruction

 

 

 

Start Time

 

 

 

 

Approved By

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

AM

 

PM

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Method of Disposal/Destruction

Signature

Location of Disposal/Destruction (physical address) including room # or name

Date

PERSONNEL CONDUCTING DISPOSAL/DESTRUCTION

Name

Name

Title

 

Professional

 

 

License #

Title

 

Professional

 

 

License #

 

REQUESTOR AFFIRMATION

I hereby affirm that the controlled substances listed on the Controlled Substances Inventory Form (DOH-166) will be disposed of/destroyed as proposed in accordance with applicable federal, state and local laws. No controlled substances will be disposed of/destroyed without written permission of the New York State Department of Health’s Bureau of Narcotic Enforcement.

Name

 

 

Title

Signature

 

Date

SECTION II -- STATEMENT OF DISPOSAL/DESTRUCTION (to be completed following disposal/destruction)

We, the undersigned, affirm that the controlled substances listed on the Controlled Substances Inventory Form (DOH-166) were disposed of/destroyed on

/

/

as approved in accordance with applicable federal, state and local laws.

 

 

 

 

 

 

 

 

 

 

Name

Name

Signature

Signature

DISPOSAL/DESTRUCTION MUST BE COMPLETED EXACTLY AS PROPOSED.

NO SUBSTITUTIONS OF DATE, TIME, LOCATION OR PERSONNEL WILL BE PERMITTED

WITHOUT PRIOR APPROVALBY THE BUREAU OF NARCOTIC ENFORCEMENT.

DISPOSAL/DESTRUCTION ACTIVITIES MAY BE OBSERVED BY THE BUREAU OF NARCOTIC ENFORCEMENT. ALL CONTROLLED SUBSTANCES BEING DISPOSED OF OR DESTROYED ARE SUBJECT TO PHYSICAL INVENTORY.

DOH-2340 08/19

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