NEW YORK STATE DEPARTMENT OF HEALTH
Narcotic Enforcement
DOH-3848 1/20 Page 1 of 2
Semi-Annual Controlled Substance
Inventory Form for EMS Agencies
Title 10 of New York State Rules and Regulations Part 80.136(j)(1) states: “Within 30 days of June 30 and December 31 of each year, the ALS Agency
shall submit a report for that six month period to the Department signed by the agent which report shall include the following:…”. All agents
and members of an ALS Agency are under a continuing duty to report immediately to the Department and the medical director any loss, theft,
or diversion of controlled substances.
This report must be received at BNE and BEMS within 30 days of the end of reporting period
Semi-Annual Ending on: June 30
December 31 of year
Check box for correct semi-annual period
Agency Name
Address Line 1 Address Line 2
City State Zip County
BNE Class 3C License # NYS EMS Agency Code # DEA Registrant Name
CS Agent’s Name DEA Registrant Contact Name
CS Agent’s Telephone # Contact’s Telephone # DEA Registration #
CS Agent’s E-mail Address Contact’s E-Mail Address
CONTROLLED
SUBSTANCE
NAME Fentanyl Midazolam Morphine Ketamine
Amount per ml (e.g. 1mg/ml)
Last Periods Ending
Inventory Amount (ml)
Add total Amount Received (ml)
Subtract Total Amount Utilized (ml)
Subtract Total Amount
Destroyed/Wasted (ml)
Subtract Total Amount Returned to
Pharmacy or Reverse Distributor (ml)
*Subtract total Amount Lost (ml)
Total Ending Inventory
Physical Inventory Count
(stocks plus sub-stocks)
Total quantity carried in each
sub-stock (e.g. 400 mcg)
Use additional forms if reporting more than 5 controlled substance medications
* Form DOH – 2094 must accompany this report if there is any loss of controlled substances
