Controlled Substances (Ii-V) Administered/dispensed Log printable pdf download

Controlled Substances (Ii-V) Administered/dispensed Log

Appendix B:

Appendix B Effective 09/2016

Record of Controlled Substances (II-V) Administered/Dispensed

Page ___ of ___

One log sheet must be completed for each container of Controlled Substances

This grey section must be filled

PI’s Name:

CSUA# :

Date Received:

Drug Name

out upon receipt

Unique Bottle ID #:

Container Amount i.e 100 mg, 100 mL:

Lot or Serial #:

Amount removed

In Vitro/ /IACUC

Authorized Personnel

(units) from Original

Amount

Date

Balance (units)

Protocol #

Name

Signature

Vial

Wasted

i.e 100 mg, 100 mL

If this controlled substance is no longer needed, submit pick-up request

controlled substance.

•

You must keep the original log sheet(s) in your files for 3 years either from the date of disposal or date of complete use: Retain until:

•

When this controlled substance is completely used up, request disposal of empty bottles at

https:// apps/waste/controlsub/cscollect.jsp

and have copies of the log sheet available.

•

All controlled substances and usage log sheets must be kept adequately secured in a proper drawer or safe.

•

Any log discrepancies, suspected misuse or theft of controlled substances must be reported immediately to EH&S 949-824-6200.

•

Ensure Schedule II controlled substance inventory and records are maintained separately from Schedule III – V controlled substances.

Controlled Substances (Ii-V) Administered/dispensed Log