Controlled Substance Usage Log

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CONTROLLED SUBSTANCE USAGE LOG
1. One log sheet must be completed for each container of Controlled Substance. If the material is converted or diluted, start a new
log form to track that usage; reference the original container’s lot or serial # and original bottle #.
2.
Controlled Substance usage must be tracked on a per dose (use) basis and only by an Authorized User. Record total quantity of
the substance to the nearest metric unit weight/volume or the total number of units finished form.
3.
Controlled Substances Dispensed in Bulk Form must be returned to the DEA Registrant inventory daily.
DEA Registrant:
Building:
Room:
Drug Name:
Lot or Serial #:
Container Amount:
Expiration Date:
Strength:
Form:
Bulk*
Finished
(Circle One)
Date Received:
Date Returned: *
Unique Bottle Number assigned
Date Remainder was Disposed:
by DEA Registrant*:
Date
Protocol#
Amount
Amount
Administered to:**
Name of Authorized User (print)
Initial
Removed (in
Remaining (in
mls, tablets,
mls, tablets,
etc)
etc.)
*This information is a unique number added to the controlled substance bottle in some labs. This is not required.
**Number of Animals and Species, i.e., (5 mice) or describe other administration.
DEA Registrant Signature:
Date:
Instructions: Registrant should maintain completed form in his/her records for at least two years from the date of the last
transaction.
ORSP – August 2015

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