Daily Controlled Drug And Key Inventory Form
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3DEPARTMENT OF HEALTH SERVICES
COUNTY OF LOS ANGELES
SUBJECT:
DAILY CONTROLLED DRUG AND KEY INVENTORY FORM
REFERENCE NO. 702.2
Provider Agency: ___________________________________
ALS Unit: _________________
SIGNATURE/LICENSE #
MIDAZOLAM
MORPHINE SULFATE
FENTANYL
SIGNATURE/LICENSE #
5 mg/1 ml
4 mg/1 ml
100 mcg/2ml
RELINQUISHING
DATE
TIME
RECEIVING PERSONNEL
PERSONNEL
maximum 8 unit dose
maximum 15 unit dose
Maximum 15 unit doses
Out
In
Out
In
Out
In
Start
Total
Start
Total
Start
Total
(-)
(+)
(-)
(+)
(-)
(+)
Revised 4-1-14
PAGE 1 OF 3
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