Fillable Reporting Form For Drug Diversion and Impairment New (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Reporting Form For Drug Diversion and Impairment New (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Reporting Form For Drug Diversion and Impairment New (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 2 pages long and contains:

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  • 12 check-boxes
  • 53 other fields

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New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Reporting Form
For Drug Diversion and Impairment
(Please print clearly.)
Please be advised that any information you supply on this complaint form may be subject to public disclosure. If an investigation into the
matter is conducted, the information is subject to public disclosure only after the completion of the investigation. You are also advised
that the completed reporting form is a “government record,” which the Board may be obligated to provide to anyone making a request
pursuant to the Open Public Records Act (OPRA).
You are further advised that pursuant to Section 4B of Executive Order No. 26, information concerning any individual’s medical, psychiatric
or psychological history, diagnosis, treatment or evaluation is not a government record subject to public access.
This case may be assigned to the Enforcement Bureau within the Division of Consumer Affairs. If this is the case, please be aware that
you may be contacted for follow-up investigative activity. The Board of Nursing must be advised of any new information that develops
once a case is reported.
Facility Information Complaint Reported Against
Name of Facility: __________________________________ Name: _________________________________________
Name and Title of Person Reporting: ___________________ Current Employment Status:
_________________________________________________ Suspended: Yes No ____________________
City:_____________________________________________ ______________________________________________
State: ______________________ ZIP code: _____________ Terminated: Yes No ____________________
Telephone Number: _________________________________ ______________________________________________
Fax Number: _____________________________________ Referred to RAMP: Yes No ______________
E-Mail Address: ___________________________________ ______________________________________________
Was the C.D.S. Theft - Loss Report made to the Drug Control Unit?
Is the employee aware of the facility’s investigation?
Yes No Yes No
Were the local police notied? Yes No Home Adress: __________________________________
If “Yes,” which police station? ________________________ City: _________________________________________
Who is the police contact person?______________________ State: _______________________ ZIP code: _________
_________________________________________________ Telephone Number: ______________________________
Date of Report: ____________________________________ Title: _________________________________________
License Number (if known): _______________________
Licensed by another state’s Board of Nursing: _________
Licensed by another N.J. professional board: __________
Date of Report: _________________________________
(include area code)
(include area code)
(include area code)
(Reason)
(Reason)
(Reason)
1. For C.D.S. loss, theft or suspected or documented diversion, please describe the facts of your complaint regarding the
substance abuse/impairment issue being reported addressing each of the following:
a) The nature of the complaint
b) The type and amount of medication lost or diverted and approximately when this activity occurred,
c) The type of dispensing system in place - manual or automatic,
d) The nursing personnel potentially associated with this complaint, and why,
e) The results of facility review, including testimony of patients and staff regarding the suspect’s behavior and nursing
practice including documentation of assessment of need for C.D.S., its administration, and documentation of
administration,
f) The existence of any reports or memoranda of investigation prepared regarding this matter, and
g) The agencies notied (e.g. the Board of Nursing, A.T.D. Committee, others).
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. Was the person suspected of diversion or substance abuse confronted? If the answer to this question is “yes,”
by whom? Did the person admit to the allegations of diversion or substance abuse? Please provide a fax
copy of any written statement of admission by the nurse, the incident report or an afdavit.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. Did the person who admitted to diversion or substance abuse make contact with RAMP?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. Please attach scanned copies of all materials that support your suspicion or allegation of substance abuse
to this e-report form. If your facility does not have scanning capabilities, please forward a copy of the support materials
to the mailing address below, to the attention of Deborah Zuccarelli, BSN, RN, Alternative to Discipline Supervisor.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. I certify that the statements made by me in this complaint are true and any documents attached electronically or mailed
to the Board of Nursing ofce are true copies. I am aware that if any of the statements made by me are willfully false, I am
subject to punishment.
_______________________________________________
______________________________________
Date Signature of Person Reporting*
* The person who has completed the form must sign this certification, electronically if possible. Supporting
documentation (scanned PDF les) may be e-mailed to Ramp@dca.lps.state.nj.us or hard copies may be mailed to the
following address:
State of New Jersey
New Jersey Board of Nursing
Attention: Deborah Zuccarelli, BSN, RN
Alternative to Discipline Supervisor
P.O. Box 45010
Newark, New Jersey 07101
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Reporting Form For Drug Diversion and Impairment New (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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