Controlled Substance Usage Log printable pdf download

Controlled Substance Usage Log

UCSC Environmental Health & Safety

Controlled Substance Program

Controlled Substance Usage Log

Environmental Health & Safety

Principal Investigator:

Dilution Date:

Expiration Date:

CS Name:

Diluted from:

Lot #

Amount/container (e.g., 100 mg, 10 ml):

Concentration: (e.g., 10 mg/ml):

Container ID:_________________________

Each container must have an individual log sheet.

Amount

Date

User’s Printed Name and Signature

Reason for Use/ Animal Protocol # /Comments

Used

Remaining

CS transferred to Student Pharmacy disposal? Y

If Yes: CSH Initials

Date

Disposal #:

CS is completely used? Y

If Yes: Empty bottle disposed by:

Date



This log must be kept in the controlled substance storage drawer or safe. The log balance must match the physical balance of CS at all times.



This log must be retained in the lab for 3 years from either the date of disposal or date of complete use:



Any log discrepancies, suspected mis-use, or theft of controlled substance must be reported to EH&S immediately.



When this controlled substance is completely used, deface label(s) and discard as regular trash.



Any breakage or loss of materials must be recorded and initialed by the individual responsible and co-signed by a witness to the loss.

Use Log_04_2017

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Controlled Substance Usage Log