Medication Request Form (Mrf)

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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