Controlled Substance Use Log printable pdf download

Controlled Substance Use Log

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Controlled Substance Use Log

Complete a log sheet for each container of Controlled Substance. If the material is diluted, start a new log form to track usage of

each new container and use the original container's log or serial # and original bottle # assigned by the laboratory.

Principal Investigator

Building:

Room

Drug Name:

Lot or Serial Number:

Amount Received:

Expiration Date:

Strength:

Form:

Liquid

Powder

Date Received:

Unique Container Number:

Date/time disposed (if applicable)

When content has been consumed, forward a copy of the completed controlled substance use log to EHS, 262 Alexander Street

Amount

removed (ml,

Name of Person

Remaining

mg, etc.)

Withdrawing Medication

in Vial (ml,

Protocols, Species and/or identification of

Date

Used

Loss

mg etc.)

usage

(Printed Name)

Initials

Material drawn up for dosing that was not used or could not be fully extracted; e.g., syringe hub loss.

*Medication that has been drawn up and not administered should be labeled as DEA Waste – Do Not Use, and secured in the lab's

controlled substance lock box until it can be properly disposed of by Environmental Health and Safety.

Receiving Information

Purchase Order:

Requisition:

Vendor:

Comments:

For EHS use: Vial removed from DEA Inventory on ___________ by _____________________________.

Controlled Substance Use Log