Report Of Loss Of Controlled Substances

ADVERTISEMENT

THE BOARD OF REGISTRATION IN PHARMACY
REPORT OF LOSS OF CONTROLLED SUBSTANCES
Pursuant to the Board’s regulations at 247 CMR 6.02(10), registrants are required to report the loss of a significant amount of
controlled substances upon discovery. When a drug loss is discovered, complete a DEA Form 106 AND the Board’s Report
of Loss of Controlled Substances Form. Email both completed forms to the Board at DHPL-OPP.ADMIN@state.ma.us
within seven days of discovery of the loss.
1. Name and Address of
2. Board License
3. Date
Registrant
Number
Submitted
4. Date of Theft / Loss
5. Theft Reported to Police?
6. Name and Phone of Police Dept.
7. Type of Theft / Loss
Employee Pilferage/Diversion (See Item 10)
Customer Theft
Armed Robbery
 Other- Specify: _________________________________________
Break-in
Lost in Transit
8. What security measures have been taken to prevent future theft / loss?
9. Filer Name, Title, and Contact Information:
10. The following applies when Type of Theft/Loss (Box 7) is “Employee Pilferage/Diversion”:
Submit the following information:
A copy of any police reports filed in connection with this matter
The name of the employee allegedly engaged in pilferage, and license number, if applicable
If the employee is a licensee, submit the following information:
Any and all loss prevention reports, including, but not limited to, any signed voluntary statement or promissory
notes provided by the licensee
The last known contact information for the licensee (address, phone numbers, email addresses, etc.)
11. List the controlled substances that were lost or stolen:
NDC
Trade Name
Quantity Lost
Number

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go