UCSC Environmental Health & Safety
Controlled Substance Program
Controlled Substance Usage Log
Environmental Health & Safety, UCSC
Amount/container (100 mg, 5 ml)):
Container ID ___________________________________
Reason for Use/ Animal Protocol #/
Conc. / Vial
User’s Printed Name and Signature
***See Individual Dilution Log Sheets ***
CS transferred to Student Pharmacy disposal? Y
If Yes: CSH Initials
CS is completely used? Y
If Yes: Empty bottle disposed by:
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.