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? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names |
DEA FORM 106 |
Report of Theft or Loss of Controlled Substances |
OMB No. |
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
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 FORM 106 |
Report of Theft or Loss of Controlled Substances |
OMB No. |
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LIST OF CONTROLLED SUBSTANCES LOST OR STOLEN |
U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division
Examples
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Trade Name of Substance or Preparation |
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NDC Number |
Name of Controlled Substance in Preparation |
Dosage Strength |
Dosage Form |
Total Quantity |
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Lost or Stolen |
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Desoxyn |
Methamphetamine Hydrochloride |
5 mg |
Tablets |
300 |
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Demerol |
Meperidine Hydrochloride |
50 mg/ml |
Vial |
150 ml |
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Robitussin |
Codeine Phosphate |
2 mg/cc |
Liquid |
5676 ml |
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Remarks: (Optional) |
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Express Quantity |
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in Dosage Units, |
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or Milliliters for |
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Liquids |
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Form
DEA FORM 106 |
Report of Theft or Loss of Controlled Substances |
OMB No. |
Form |
LIST OF |
U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division
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MailBack Package |
Inner Liner |
Unique Identification Number(s) |
Size of Inner Liner |
Total Quantity Lost or |
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Stolen |
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Examples |
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X |
X |
CRL1201 |
5 GALLON |
1 |
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MBP1106, MBP1108 – MBP1110, MBP1112 |
N/A |
5 |
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X |
CRL1007 – CRL1027 |
15 GALLON |
21 |
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Remarks: (Optional) |
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Express in Total |
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Quantities |
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If you are an authorized Retail Pharmacy or Hospital/Clinic with an onsite Pharmacy and reporting a theft or loss at a
________________________________________________________ |
______________________________________________________________ |
Name of LTCF |
Address, City, State, Zip Code |
Form
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. |
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: ______________________________________________________ |
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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
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
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