Fillable Form 106: Report of Theft or Loss of (Department of Justice)

Fill Online, Printable, Fillable, Blank Form 106: Report of Theft or Loss of (Department of Justice) Form

Use Fill to complete blank online DEPARTMENT OF JUSTICE (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 106: Report of Theft or Loss of (Department of Justice)

On average this form takes 54 minutes to complete

The Form 106: Report of Theft or Loss of (Department of Justice) form is 4 pages long and contains:

  • 1 signature
  • 25 check-boxes
  • 202 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Department of Justice

BROWSE DEPARTMENT OF JUSTICE (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
U.S. Department of Justice
Report of Theft or Loss of Controlled Substances
Drug Enforcement Administration
DEA FORM
106
Diversion Control Division
OMB No. 1117-0001 (Exp. Date 7/31/2023)
Type of Report: (check one box only) New Report Amendment Key (prior report dated): __________________________________
1. DEA Registration Number: _____________________________________________________
Name of Business: ___________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
City: ______________________________________________________________________ State: ____________ ZIP Code: _____________________
Point of Contact: ________________________________________________________________________________
Email Address: _____________________________________________________________ Phone No.: _______________________________
Date of the Theft or Loss (or first discovery of theft or loss): __________________________ Number of Thefts and Losses in the past 24 months: ___________
Principal Business of Registrant: Pharmacy Practitioner Manufacturer Hospital/Clinic Distributor NTP Other (Specify) __________________
2. Type of Theft or Loss:
3. Loss in Transit.
(*Fill out this section only if there was a loss in transit, or hijacking of transport vehicle.)
Name of Common Carrier: _________________________________________________________________________________________________________
Telephone Number of Common Carrier: _____________________________________ Package Tracking Number: __________________________________
Have there been losses in transit from this same carrier in the past? No Yes
(If yes, how many, excluding this theft or loss?): __________
Was the package received and accepted by the consignee? No Yes (If yes, the consignee is responsible for reporting the theft or loss.)
If the package was accepted by the consignee, did it appear to be tampered with? No Yes
Name of Consignee / Supplier: _________________________________________________________________________________________________________
Enter the Name of Consignee (if reported by the supplier), or the Name of Supplier (if the package was accepted by the consignee).
If the consignee does not have a DEA Registration Number, e.g. if this was a shipment to a patient, or a nursing home emergency kit, enter "Patient" or "Nursing Home Kit."
DEA Registration Number of Consignee / Supplier: _____________________________________________
Enter the DEA Registration Number of Consignee (if reported by the supplier), or DEA Registration Number of Supplier, (if the package was accepted by the consignee). If the
controlled substances were shipped to a non-registrant, leave blank, unless a registered pharmacy shipped to an emergency kit held on site at a nursing home. In this case, the
supplying pharmacy is required to report the theft or loss.
4. If this was a robbery, were any people injured? No Yes (If yes, how many?): ______Were any people killed? No Yes (If yes, how many?): _______
5. What is the total value of the controlled substances stolen or lost?: $ _________________________________________
(This is the amount you paid for the
controlled substances
, not the retail value.)
6. Was theft reported to Police? No Yes (If yes, fill out the following information):
Name of Police Department: ______________________________________________________________ Police Report number: ______________________
Name of Responding Officer: _____________________________________________________________________ Phone No.: ________________________
7. Which corrective measure(s) have you taken to prevent a future theft or loss?
Installed monitoring equipment (e.g. video camera). Provided security training to staff.
Increased employee monitoring (e.g. random drug tests). Requested increased security patrols by Police.
Installed metal bars or other security on doors or windows. Hired security guards for premises.
Secured Controlled Substances within safe. Terminated employee.
Other (Please describe on last page).
8. Were any pharmaceuticals or merchandise taken? No Yes
(
Estimated Value)
:
Form DEA-106 Pg. 1
-
U.S. Department of Justice
Report of Theft or Loss of Controlled Substances
Drug Enforcement Administration
DEA
FORM 106
Diversion Control Division
OMB No. 1117-0001 (Exp. Date 7/31/2023)
LIST OF CONTROLLED SUBSTANCES LOST OR STOLEN
Examples
Trade Name of Substance or Preparation NDC Number Name of Controlled Substance in Preparation Dosage Strength Dosage Form
Total Quantity
Lost or Stolen
Desoxyn 00074-3377-01 Methamphetamine Hydrochloride 5 mg Tablets 300
Demerol 00409-1181-30 Meperidine Hydrochloride 50 mg/ml Vial 150 ml
Robitussin A-C 00031-8674-25 Codeine Phosphate 2 mg/cc Liquid 5676 ml
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Remarks: (Optional)
Express Quantity
in Dosage Units,
or Milliliters for
Liquids
Form DEA-106 Pg. 2
________________________________________________________ ______________________________________________________________
U.S. Department of Justice
Report of Theft or Loss of Controlled Substances
Drug Enforcement Administration
DEA FORM 106
Diversion Control Division
OMB No. 1117-0001 (Exp. Date 7/31/2023)
Form DEA-106 (10/23/2020) Pg. 3 LIST OF MAIL-BACK PACKAGES OR INNER LINERS LOST OR STOLEN
Mail-Back Package Inner Liner Unique Identification Number(s) Size of Inner Liner
Total Quantity Lost or
Stolen
X MBP1106, MBP1108 – MBP1110, MBP1112 N/A 5
X CRL1007 – CRL1027 15 GALLON 21
X CRL1201 5 GALLON 1
1.
2
3.
4.
5.
6.
7.
8.
Remarks: (Optional)
Express in Total
Quantities
Examples
If you are an authorized Retail Pharmacy or Hospital/Clinic with an onsite Pharmacy and reporting a theft or loss at a Long-Term Care Facility (LTCF), provide name and
address of LTCF.
Name of LTCF Address, City, State, Zip Code
Form DEA-106 Pg. 3
U.S. Department of Justice
Report of Theft or Loss of Controlled Substances
Drug Enforcement Administration
DEA FORM 106
OMB No. 1117-0001 (Exp. Date 7/31/2023)
Diversion Control Division
Describe any other corrective measure(s) you have taken to prevent a future theft or loss:
Enter remarks, if required. Description of how theft or loss occurred.
The foregoing information is correct to the best of my knowledge and belief: By signing my full name in the space below, I hereby certify that the foregoing information furnished
on this DEA Form 106 is true and correct, and understand that this constitutes an electronic signature for purposes of this reporting requirement only.
Signature: ______________________________________________________
Title: _________________________________________________________ Date Signed: _____________________________
NOTICE: In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control number for
this collection of information is 1117-0001. Public reporting burden for this collection of information is
estimated to average 20 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information.
Freedom of Information: Please prominently identify any confidential business information per 28 CFR
16.8(c) and Exemption 4 of the Freedom of Information Act (FOIA). In the event DEA receives a FOIA
request to obtain such information, DEA will give written notice to the registrant to obtain such information.
DEA will give written notice to the registrant to allow an opportunity to object prior to the release of
information.
Privacy Act Information
AUTHORITY: Section 301 of the Controlled Substances Act of 1970 (PL 91-513)
PURPOSE: Reporting of unusual or excessive theft or loss of a Listed Chemical
ROUTINE USES: The Controlled Substances Act authorizes the production of special reports
required for statistical and analytical purposes. Disclosures of information from this system are
made to the following categories of users for the purposes stated:
A. Other Federal law enforcement and regulatory agencies for law enforcement and
regulatory purposes.
B. State and local law enforcement and regulatory agencies for law enforcement and
regulatory purposes.
EFFECT: Failure to report theft or loss of Listed Chemicals may result in penalties under 21
U.S.C. § 842 and § 843 of the Federal Criminal Code.
Form DEA-106 Pg. 4
Save Form
Print Form
Reset Form
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 106: Report of Theft or Loss of (Department of Justice)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document