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Department of Law and Public Safety Enforcement Bureau/Drug (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 1 signature
  • 18 check-boxes
  • 206 other fields

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Page 1
Department of Law and Public Safety
Enforcement Bureau/Drug Control Unit
P.O. Box 45045
Newark, New Jersey 07101


State regulations require registrants to submit a detailed report of any theft or loss of FRntrolled substances. Complete this
two-page form and then forward it to the address noted above. Reports may be clearly hand-printed.
1. Name of the registrant (include store number, if applicable) 2. Telephone number
(Include area
code)
__________________________________________________________________________________
1a. Address of the registrant
2a. Professional License No. of registrant
___________________________________________________________________________________ _____________________________
Street City State ZIP code
( )
DDC-52
Revised 2/12
3. Principal business of registrant (Check one) 4. D.E.A. registration number 5. N.J.C.D.S. number
1
Pharmacy 4 Manufacturer/Distributor 2-Letter Prex 7-Digit Sufx 1-Letter Prex 8-Digit Sufx
2
Practitioner 5 Other
3
Hospital/Clinic
9. Name and address of the police dept. and the investigating ofcer who
was notied of the theft/loss.
13. What security measures have been taken to prevent future thefts or losses?
14. Theft or Loss Remarks/Details:
6. Date and time of theft or loss 7. Number of thefts or losses by 8. Type of theft or loss
(Indicate date detected, if known) registrant in the last 12 months 1 Break-in 6 Employee-Unlicensed
2 Armed Robbery 7 Miscount
3 Customer Theft 8 Prescription Filling Error
4 Transit-Theft 9 Other/Unknown
5 Employee-Licensed (provide name and license number)
10. If lost in transit, provide the name of the carrier. 11. Have you experienced loss in transit from the same carrier in the
past? Yes No
________________________________________________________ If “Yes,” how many? ________________________________
12. Was the incident reported to the D.E.A.? Yes No
If “Yes,” provide the address and telephone number of the nearest D.E.A. ofce that received the registrant’s report about the incident.
_____________________________________________________________________________________________________________________
Ofce contacted and telephone number

According to Controlled Dangerous Substances regulations N.J.A.C. 13:45H-2.4(c) and 2.5(d), the registrant shall notify the Drug Control Unit of any theft or
loss of any controlled substances upon discovery. The supplier shall be responsible for reporting in-transit losses of controlled substances by the common
or contract carrier selected pursuant to discovery. The registrant shall also complete a DDC-52 form regarding any theft or loss. Thefts must be reported
the controlled substances are subsequently recovered and/or the responsible parties are identied and action is taken against them.
Page 2
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
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I certify that the foregoing information is correct to the best of my knowledge and belief.
_________________________________________ __________________________________________
Signature Print name and professional license number (if applicable)
_________________________________________ __________________________________________
Title Date
_______________________________________________________________________________________
Business address City State ZIP code Telephone number (include area code)
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Department of Law and Public Safety Enforcement BureauDrug (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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