Fillable Controlled Substance Report for Emergency Medical Services Agencies (New York State)

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Controlled Substance Report for Emergency Medical Services Agencies (New York State)

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DOH-4352 (12/16) p 1 of 2
DRAFT
• This report must be submitted pursuant to PHL Article 33 and 10NYCRR Part 80
within 30 days following end of each required reporting period.
• Complete a separate report for each controlled substance carried
• Retain a copy of this report for a minimum of 5-years
Controlled Substance Information
Name
Dosage Supplied (mg/ml or mcg/ml)
How Supplied (ampule, vial, syringe, etc.)
Agency Information
Name NYS Agency Code NYS CS License No. Business Phone
Address City State Zip County
Inventory Record Response/Transport History
Total Quantity at Start
of Reporting Period
Stock:
Sub-Stock:
Total of Above:
Total Number of
EMS Responses and
Transports this Period
Responses Transports
Total Quantity
Received Through
DEA Registrant
Total Number of Patients
Receiving this CS Medication
Adult Pediatric
Total Quantity
Administered
and Wasted
Number of Quality Assurance
Reviews Conducted by the
Service Medical Director*
Adult Pediatric
Total Quantity
Returned to Pharmacy
or Reverse Distributor
Number of Adverse Reactions
to Administration
Adult Pediatric
Total Quantity Lost
(attach copy of
DOH-2094)
Total Number of EMS Providers
Authorized to Administer
CS Medications
EMT-P EMT-CC
Total Quantity
Accounted from Records
(stocks and sub-stocks)
Paper Tally
Quantity Carried in
Each Sub-Stock
Physical Inventory Count
(stocks and sub-stocks)
Physical Tally
* 100% Agency Medical Director Review Required for Fentanyl and Ketamine Administrations
Do NOT Attach PCRs to this Form
Reporting Period
All Controlled Substances (Semi-Annual)
January 1 - June 30, 20
July 1 - December 31, 20
Fentanyl and Ketamine (Quarterly)
January 1 - March 31, 20
April1 - June 30, 20
July 1 - September 30, 20
October 1 - December 31, 20
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services and Trauma Systems
Bureau of Narcotics Enforcement
Controlled Substance Report
for Emergency Medical Services Agencies
DOH-4352 (12/16) p 2 of 2
Attach
• Any Unusual Incident Reports Involving Controlled Substance Medications and/or Loss (DOH Form-2094)
• Any Reports or Findings of Significant Increases or Decreases in CS Medication Administrations
Comments (attach additional pages as needed)
Any Experienced Shortages of this CS Medication? (if yes, describe)
I (name of CS Agent), certify that on (date),
I conducted an actual physical inventory of the controlled substance recorded on this document. Losses have been reported on a “Loss
of Controlled Substance Report” DOH-2094 and have been submitted to BNE and a copy of the form has been enclosed. Overages are
explained on a separate attached report.
I affirm that this is a true and accurate record of the controlled substance utilization by the agency.
Name of Agent (print) Signature of Agent Date
Name of CEO (print) Signature of CEO Date
Name of Medical Director (print) Signature of Medical Director Date
Send Completed Report to:
New York State Department of Health
Bureau of Emergency Medical Services and Trauma Systems
875 Central Avenue
Albany, New York 12206
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Controlled Substance Report for Emergency Medical Services Agencies (New York State)

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Completed 1 June 2021

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