Form Dea 106 – Fill Out and Use This PDF

The DEA Form 106 is officially used to report the theft or loss of controlled substances to the U.S. Department of Justice Drug Enforcement Administration Diversion Control Division. This critical form ensures that significant thefts or losses are documented accurately, facilitating the necessary legal and regulatory responses to such incidents. For those needing to complete this form, actionable steps and a straightforward process are essential. Click the button below to start filling out your DEA 106 Form.

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Form Dea 106 PDF Details

In the intricate landscape of controlled substance management within the United States, the DEA Form 106 plays a critical role. This form, officially named the "Report of Theft or Loss of Controlled Substances," is an essential document for registrants under the U.S. Department of Justice Drug Enforcement Administration's (DEA) Diversion Control Division. It serves as a formal notification mechanism for reporting any theft or loss of controlled substances, which are regulated due to their potential for abuse and dependency. The versatility of this form is evident as it accommodates reports ranging from in-transit losses to outright thefts, inclusive of details such as the DEA Registration Number, the name and address of the business, and a comprehensive description of the stolen or lost substances including their quantity and value. Further complexity is added with sections dedicated to specifics such as the involvement of common carriers in transit losses, injury or fatality during a robbery, and the outcomes of police reports. The form also prompts registrants to outline the preventive measures they have implemented to deter future incidents. Moreover, its usage extends beyond immediate theft or loss reporting, providing options for amendments to initial reports. With the responsibility of ensuring the integrity of controlled substance handling and deterring diversion to illicit channels, the DEA Form 106 embodies a crucial checkpoint in the regulatory framework that safeguards public health and safety.

Question	Answer
Form Name	Form Dea 106
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	Reporting of Theft or Significant Loss of ... - Federal Register

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DEA FORM 106	Report of Theft or Loss of Controlled Substances
	OMB No. 1117-0001 (Exp. Date 7/31/2023)

U.S. Department of Justice

Drug Enforcement Administration

Diversion Control Division

Type of Report: (check one box only)

New Report

Amendment Key (prior report dated): __________________________________

1.DEA Registration Number: _____________________________________________________

Name of Business: ___________________________________________________________________________________________________________

Address: ___________________________________________________________________________________________________________________

City: ______________________________________________________________________ State: ____________ ZIP Code: _____________________

Point of Contact: ________________________________________________________________________________

Email Address: _____________________________________________________________ Phone No.: _______________________________

Date of the Theft or Loss (or first discovery of theft or loss): __________________________ Number of Thefts and Losses in the past 24 months: ___________

Principal Business of Registrant: Pharmacy Practitioner Manufacturer Hospital/Clinic Distributor NTP Other (Specify) __________________

2.Type of Theft or Loss: -

3.Loss in Transit. (*Fill out this section only if there was a loss in transit, or hijacking of transport vehicle.)

Name of Common Carrier: _________________________________________________________________________________________________________

Telephone Number of Common Carrier: _____________________________________ Package Tracking Number: __________________________________

Have there been losses in transit from this same carrier in the past?	No	Yes (If yes, how many, excluding this theft or loss?): __________
Was the package received and accepted by the consignee?	No	Yes (If yes, the consignee is responsible for reporting the theft or loss.)
If the package was accepted by the consignee, did it appear to be tampered with?		No	Yes

Name of Consignee / Supplier: _________________________________________________________________________________________________________

Enter the Name of Consignee (if reported by the supplier), or the Name of Supplier (if the package was accepted by the consignee).

If the consignee does not have a DEA Registration Number, e.g. if this was a shipment to a patient, or a nursing home emergency kit, enter "Patient" or "Nursing Home Kit."

DEA Registration Number of Consignee / Supplier: _____________________________________________

Enter the DEA Registration Number of Consignee (if reported by the supplier), or DEA Registration Number of Supplier, (if the package was accepted by the consignee). If the controlled substances were shipped to a non-registrant, leave blank, unless a registered pharmacy shipped to an emergency kit held on site at a nursing home. In this case, the supplying pharmacy is required to report the theft or loss.

4.If this was a robbery, were any people injured? No Yes (If yes, how many?): ______Were any people killed? No Yes (If yes, how many?): _______

5.What is the total value of the controlled substances stolen or lost?: $ _________________________________________

(This is the amount you paid for the controlled substances, not the retail value.)

6. Was theft reported to Police?

Yes (If yes, fill out the following information):

Name of Police Department: ______________________________________________________________ Police Report number: ______________________

Name of Responding Officer: _____________________________________________________________________ Phone No.: ________________________

7.Which corrective measure(s) have you taken to prevent a future theft or loss?

Installed monitoring equipment (e.g. video camera).

Increased employee monitoring (e.g. random drug tests).

Installed metal bars or other security on doors or windows.

Secured Controlled Substances within safe.

Other (Please describe on last page).

Provided security training to staff.

Requested increased security patrols by Police.

Hired security guards for premises. Terminated employee.

8. Were any pharmaceuticals or merchandise taken?

Yes (Estimated Value):

Form DEA-106 Pg. 1

DEA FORM 106	Report of Theft or Loss of Controlled Substances
DEA FORM 106	OMB No. 1117-0001 (Exp. Date 7/31/2023)
	LIST OF CONTROLLED SUBSTANCES LOST OR STOLEN

U.S. Department of Justice

Drug Enforcement Administration

Diversion Control Division

Examples


Trade Name of Substance or Preparation	NDC Number	Name of Controlled Substance in Preparation	Dosage Strength	Dosage Form	Total Quantity
Trade Name of Substance or Preparation	NDC Number	Name of Controlled Substance in Preparation	Dosage Strength	Dosage Form	Lost or Stolen
					Lost or Stolen
Desoxyn	00074-3377-01	Methamphetamine Hydrochloride	5 mg	Tablets	300
Demerol	00409-1181-30	Meperidine Hydrochloride	50 mg/ml	Vial	150 ml
Robitussin A-C	00031-8674-25	Codeine Phosphate	2 mg/cc	Liquid	5676 ml
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Remarks: (Optional)					Express Quantity
Remarks: (Optional)					in Dosage Units,
					or Milliliters for
					Liquids

Form DEA-106 Pg. 2

DEA FORM 106	Report of Theft or Loss of Controlled Substances
	OMB No. 1117-0001 (Exp. Date 7/31/2023)

Form DEA-106 (10/23/2020) Pg. 3

LIST OF MAIL-BACK PACKAGES OR INNER LINERS LOST OR STOLEN

U.S. Department of Justice

Drug Enforcement Administration

Diversion Control Division


	Mail-Back Package	Inner Liner	Unique Identification Number(s)	Size of Inner Liner	Total Quantity Lost or
	Mail-Back Package	Inner Liner	Unique Identification Number(s)	Size of Inner Liner	Stolen
					Stolen
Examples
Examples	X	X	CRL1201	5 GALLON	1
	X		MBP1106, MBP1108 – MBP1110, MBP1112	N/A	5
		X	CRL1007 – CRL1027	15 GALLON	21

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	Remarks: (Optional)				Express in Total
					Quantities

If you are an authorized Retail Pharmacy or Hospital/Clinic with an onsite Pharmacy and reporting a theft or loss at a Long-Term Care Facility (LTCF), provide name and address of LTCF.

________________________________________________________	______________________________________________________________
Name of LTCF	Address, City, State, Zip Code

Form DEA-106 Pg. 3

DEA FORM 106	Report of Theft or Loss of Controlled Substances
	OMB No. 1117-0001 (Exp. Date 7/31/2023)

U.S. Department of Justice

Drug Enforcement Administration

Diversion Control Division

Describe any other corrective measure(s) you have taken to prevent a future theft or loss:

Enter remarks, if required. Description of how theft or loss occurred.

The foregoing information is correct to the best of my knowledge and belief: By signing my full name in the space below, I hereby certify that the foregoing information furnished on this DEA Form 106 is true and correct, and understand that this constitutes an electronic signature for purposes of this reporting requirement only.

Signature: ______________________________________________________
Title: _________________________________________________________	Date Signed: _____________________________

NOTICE: In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection of information is 1117-0001. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Freedom of Information: Please prominently identify any confidential business information per 28 CFR 16.8(c) and Exemption 4 of the Freedom of Information Act (FOIA). In the event DEA receives a FOIA request to obtain such information, DEA will give written notice to the registrant to obtain such information. DEA will give written notice to the registrant to allow an opportunity to object prior to the release of information.

Privacy Act Information

AUTHORITY: Section 301 of the Controlled Substances Act of 1970 (PL 91-513)

PURPOSE: Reporting of unusual or excessive theft or loss of a Listed Chemical

ROUTINE USES: The Controlled Substances Act authorizes the production of special reports required for statistical and analytical purposes. Disclosures of information from this system are made to the following categories of users for the purposes stated:

A. Other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes.

B. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.

EFFECT: Failure to report theft or loss of Listed Chemicals may result in penalties under 21 U.S.C. § 842 and § 843 of the Federal Criminal Code.

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Form DEA-106 Pg. 4

How to Edit Form Dea 106 Online for Free

Filling out the Form Dea 106 form is easy with this PDF editor. Stick to the next steps to create the document in a short time.

Step 1: The first step is to click on the orange "Get Form Now" button.

Step 2: After you've accessed the Form Dea 106 editing page you'll be able to discover the different functions you'll be able to carry out regarding your document from the upper menu.

To prepare the Form Dea 106 PDF, enter the information for all of the segments:

Put down the details in the No Have there been losses in, Yes If yes how many excluding this, Yes, Name of Consignee Supplier Enter, DEA Registration Number of, If this was a robbery were any, Yes If yes how many Were any, Yes If yes how many, What is the total value of the, This is the amount you paid for, Was theft reported to Police, Yes If yes fill out the following, Name of Police Department Police, Name of Responding Officer Phone, and Which corrective measures have field.

step 2 to entering details in Form Dea 106

The software will request you to include certain necessary data to instantly submit the field Which corrective measures have, Installed monitoring equipment eg, Provided security training to, Were any pharmaceuticals or, Yes Estimated Value, and Form DEA Pg.

Through box s e l p m a x E, Demerol, Robitussin AC, Meperidine Hydrochloride, Codeine Phosphate, mgml, mgcc, Vial, and Liquid, state the rights and obligations.

End by reviewing all these fields and filling them in as required: Remarks Optional, Form DEA Pg, and Express Quantity in Dosage Units.

Step 3: Click the button "Done". The PDF form is available to be exported. It is possible to upload it to your laptop or email it.

Step 4: It's going to be more convenient to create duplicates of the form. There is no doubt that we won't disclose or read your particulars.

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