The Drug Enforcement Administration (DEA) has authorized the University of Iowa to dispose of controlled substances (CS) used in research at the University of Iowa.
Documentation of Controlled Substance(s) Disposal in a DEA Registrant’s Location (Example)
The information recorded on this form must also be recorded on DEA Form 41. A copy of the DEA Form 41 must be given to EHS.
Each registrant must also keep a copy of the completed DEA Form 41 as required by 21 CFR 1304.22.
Disposal Date: __________________________________
DEA Licensed Registrant (Print Name): _____________________________________________________________
DEA Registration Number: ___________________________
DEA Registrant Address ______________________________________________________________________________
(As appears on DEA Form 223)
Disposal Location (Room No. and Building): ________________________________________________________________________________
CS Disposal Performed by: ____________________________________________________________________
______________________________________________________________
Print Name
Signature
Date
Employee Who Has Witnessed Disposal: _________________________________________________ _____________________________________________________________
Print Name
Signature
Date
Controlled Substance Name
Unopened/Expired
Opened/Partially
Abandoned/ Orphaned
DEA Form 41
Destruction Method
Line
(and Lot number if known)
Containers
Used Containers
Containers
Completed and copies
No
provided to EHS
Qty. Destroyed (g or ml) Qty. Destroyed (g or ml) Qty. Destroyed (g or ml)
1
Yes
2
Yes
3
Yes
4
Yes
5
Yes
6
Yes
7
Yes
8
Yes
9
Yes
10
Yes
1), The laboratory notifies Environmental Health & Safety (EHS) that it has a controlled substance that needs disposal. 2). An EHS representative will visit the lab prior to disposal.
3). On the agreed upon date of disposal, EHS will bring a Controlled Substance Disposal Kit and provide directions on how to conduct the disposal. 4). Disposal will be conducted by the
Registrant or their duly appointed authorized employee and witnessed by an EHS employee. 5). Disposal consists of blending an aqueous solution of the controlled substance within a
container of kitty litter. 6). EHS will take possession of and dispose of the container of controlled substance/kitty litter blend. 7). This form can be collocated with the respective daily
dispensation record (Appendix B4 of Controlled Substances Guidelines) (or printed on the backside of Appendix B4).
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