Dea Form 106 - Rx-Wiki
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1
2REPORT OF THEFT OR LOSS
U.S. Department of Justice
OF CONTROLLED SUBSTANCES
Drug Enforcement Administration
Federal Regulations require registrants to submit a detailed report of any theft or loss of Controlled Substances to the Drug
Enforcement Administration.
OMB APPROVAL
No. 1117-0001
Complete the front and back of this form in triplicate. Forward the original and duplicate copies to the nearest DEA Office.
Retain the triplicate copy for your records. Some states may also require a copy of this report.
1. Name and Address of Registrant (include ZIP Code)
2. Phone No. (Include Area Code)
ZIP CODE
3. DEA Registration Number
4. Date of Theft or Loss
5. Principal Business of Registrant (Check one)
1
Pharmacy
5
Distributor
2 ltr. prefix
7 digit suffix
2
Practitioner
6
Methadone Program
3
Manufacturer
7
Other (Specify)
4
Hospital/Clinic
County in which Registrant is
6.
7.
Was Theft reported
8.
Name and Telephone Number of Police Department (Include Area Code)
located
to Police?
Yes
No
9. Number of Thefts or Losses Registrant
10. Type of Theft or Loss (Check one and complete items below as appropriate)
has experienced in the past 24 months
1
Night break-in
3
5
Employee pilferage
Other (Explain)
4
6
2
Armed robbery
Customer theft
Lost in transit (Complete Item 14)
11. If Armed Robbery, was anyone:
12. Purchase value to registrant of
13 . Were any pharmaceuticals or
Controlled Substances taken?
merchandise taken?
No
Yes (Est. Value)
Killed?
No
Yes (How many)
Injured?
$
$
No
Yes (How many)
14. IF LOST IN TRANSIT, COMPLETE THE FOLLOWING:
A. Name of Common Carrier
B. Name of Consignee
C. Consignee’s DEA Registration Number
D. Was the carton received by the customer?
E. If received, did it appear to be tampered with?
Have you experienced losses in transit
F.
from this same carrier in the past?
Yes
No
No
Yes (How Many ) __________
Yes
No
15. What identifying marks, symbols, or price codes were on the labels of these containers that would assist in identifying the products?
16. If Official Controlled Substance Order Forms (DEA-222) were stolen, give numbers.
17. What security measures have been taken to prevent future thefts or losses?
PRIVACY ACT INFORMATION
Under the Paperwork Reduction Act, a person is not required to
respond to a collection of information unless it displays a currently
AUTHORITY: Section 301 of the Controlled Substances Act of 1970 (PL 91-513).
valid OMB control number.
PURPOSE: Report theft or loss of Controlled Substances.
Public reporting burden for this collection of information is estimated
ROUTINE USES: The Controlled Substances Act authorizes the production of
to average 30 minutes per response, including the time for reviewing
special reports required for statistical and analytical purposes. Disclosures of
instructions, searching existing data sources, gathering and
information from this system are made to the following categories of users for the
maintaining the data needed, and completing and reviewing the
purposes stated:
collection of information.
Send comments regarding this burden
A.
estimate or any other aspect of this collection of information,
Other Federal law enforcement and regulatory agencies for law enforcement
and regulatory purposes.
including suggestions for reducing this burden, to the Records
Management Section, Drug Enforcement Administration,
B.
State and local law enforcement and regulatory agencies for law enforcement
Washington, D.C. 20537; and to the Office of Information and
and regulatory purposes.
Regulatory Affairs, Office of Management and Budget, Washington,
EFFECT: Failure to report theft or loss of controlled substances may result in
D.C. 20503.
penalties under Section 402 and 403 of the Controlled Substances Act.
CONTINUE ON REVERSE
DEA Form
Previous edition dated 03/83 is OBSOLETE
- 106
(Dec. 1985)
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