Fillable Borip Loss Reporting Form (Commonwealth of Massachusetts)

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Borip Loss Reporting Form (Commonwealth of Massachusetts)

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The Borip Loss Reporting Form (Commonwealth of Massachusetts) form is 2 pages long and contains:

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  • 6 check-boxes
  • 261 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Adopted: 12/06/2018
Page 1 of 2
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH
Commissioner
Board of Registration in Pharmacy
Report of Loss of Controlled Substances
Pharmacy Name ___________________________________ MA License Number___________
Pharmacy Address ______________________________________________________________
City/Town __________________________State_______________ Zip Code ______________
Pharmacy Phone Number___________________________
Manager of Record name (MOR) ____________________________________________
MOR Signature ________________________________ MOR MA License Number______________
For details on what and how to report, refer to Policy 2018-05: Requirements and Procedures for
Reporting Theft or Loss of Controlled Substances:
http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/dhpl/pharmacy/pharmacy-regs/policies/
This form must be emailed to: dhpl-opp.admin@state.ma.us
Specify the name of the pharmacy and town in the subject line.
1. Date of
Theft / Loss
If form has been amended,
indicate here (i.e.-
Amendment #1):
2. Date Investigation
Concluded
3. Loss/Theft
Reported to Police?
No Yes- Name, location, and Phone # of Police Department:
______________________________________
4. Reason for Loss
Employee Pilferage/Diversion
Break-in
Lost in Transit
Customer Theft
Armed Robbery
Other Known Loss (Specify in box #8)
Unknown Loss (Specify in box #8)
5. List the controlled substance(s) that were lost or stolen, in the table “List of Controlled Substances
Lost”, at the end of this document.
6. Name of employee
(s) allegedly engaged
in pilferage, and
license number (s),
as applicable
Employee Name: ______________________________
License #: _____________
Address: _____________________________________
Phone Number: _____________
Email Address: ________________________________
7. Attached
Documents, if
applicable
Police Reports
Loss Prevention Reports
Signed voluntary statement or
promissory note
DEA Form 106
Security measures taken to prevent
future theft/loss
Other – Specify:___________
8. Additional comments:
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Professions Licensure
239 Causeway Street, Suite 500, Boston, MA 02114
Tel: 617-973-0800 TTY :
617-973-0988
www.mass.gov/dph/boards
CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
click to sign
signature
click to edit
Adopted: 12/06/2018
Page 2 of 2
List of Controlled Substances Lost
Drug Name
Dosage
Strength
Dosage
Form
Drug
Schedule
Quantity
Please direct any questions to: dhpl-opp.admin@state.ma.us
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Borip Loss Reporting Form (Commonwealth of Massachusetts)

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Completed 22 July 2020

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