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Form Dea 106 PDF Details

Form DEA 106 is a form used to report the distribution of a controlled substance. This form must be completed and filed by any individual or entity who distributes a controlled substance. The purpose of this form is to keep track of the distribution of controlled substances and help law enforcement officials investigate criminal activity. Filing this form is required by law, so it's important to understand how to complete it properly.

You'll find it beneficial to know how much time you'll need to prepare this form dea 106 and how lengthy this form is.

Question	Answer
Form Name	Form Dea 106
Form Length	4 pages
Fillable?	Yes
Fillable fields	224
Avg. time to fill out	22 min 56 sec
Other names	Reporting of Theft or Significant Loss of ... - Federal Register

12

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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?

No

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?

No

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

<![endif]>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
<![endif]>Examples
<![endif]>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

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Put down the details in the Yes, Yes, If, yes, how, many, Were, any, people, killed Yes, If, yes, how, many and Was, theft, reported, to, Police field.

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Through box mgm, gml, m, gcc Tablets, Vial, Liquid ml, ml sep, max, E and Des, oxy, nDe, mero, l, Rob, it, uss, in, AC state the rights and obligations.

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