Regulatory 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.

QuestionAnswer
Form NameForm Dea 106
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names

Form Preview Example

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 Lozyxwvutsrqpon:

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

Was the package received and accepted by the consignee?

No

If the package was accepted by the consignee, did it appear to be tampered with?

Yes (If yes, how many, excluding this theft or loss?): __________

Yes (If yes, the consignee is responsible for reporting the theft or loss.)

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

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

 

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

 

 

 

 

 

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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

 

 

 

 

 

 

 

Mail­Back Package

Inner Liner

Unique Identification Number(s)

Size of Inner Liner

Total Quantity Lost or

 

Stolen

 

 

 

 

 

Examples

 

 

 

 

 

X

X

CRL1201

5 GALLON

1

 

 

MBP1106, MBP1108 – MBP1110, MBP1112

N/A

5

 

 

X

CRL1007 – CRL1027

15 GALLON

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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

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

DEA FORM 106

Report of Theft or Loss of Controlled Substances

Drug Enforcement Administration

 

U.S. Department of Justice

OMB No. 1117-0001 (Exp. Date 7/31/2023)

Diversion Control Division

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.

Form DEA-106 Pg. 4

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