Controlled Substance Usage Log - Ucsc

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UCSC Environmental Health & Safety
Controlled Substance Program
Controlled Substance Usage Log
Environmental Health & Safety, UCSC
Principal Investigator:
Date Received:
Expiration Date:
CS Name:
PO
Lot#
Amount/container (100 mg, 5 ml)):
Concentration: (mg/ml):
Container ID ___________________________________
Amount
Amount
Reason for Use/ Animal Protocol #/
Date
Dilution ID
Conc. / Vial
User’s Printed Name and Signature
used
Remaining
Comments
***See Individual Dilution Log Sheets ***
CS transferred to Student Pharmacy disposal? Y
N
If Yes: CSH Initials
Date
Disposal #:
CS is completely used? Y
N
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 misuse, 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.
Dilution Log_04_2017

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