Form 106 Report of Theft or Loss of Controlled Substances -- DEA

REPORT OF THEFT OR LOSS OF CONTROLLED SUBSTANCES
Federal Regulations require registrants to submit a detailed report of any theft or loss of Controlled Substances to the Drug
Enforcement Administration.

OMB APPROVAL
No. 1117-0001

Complete the front and back of this form in triplicate. Forward the original and duplicate copies to the nearest DEA Office.
Retain the triplicate copy for your records. Some states may also require a copy of this report.

1. Name and Address of Registrant (include ZIP Code)

2. Phone No. (Include Area Code)
ZIP CODE

3. DEA Registration Number

4. Date of Theft or Loss

2 ltr. prefix

6. County in which Registrant is
located

1
2
3
4

7. Was Theft reported
to Police?
Yes

9. Number of Thefts or Losses Registrant
has experienced in the past 24 months

Injured?

No

8.

Distributor
Methadone Program
Other (Specify)

Name and Telephone Number of Police Department (Include Area Code)

10. Type of Theft or Loss (Check one and complete items below as appropriate)
1

Night break-in

3

Employee pilferage

5

Other (Explain)

2

Armed robbery

4

Customer theft

6

Lost in transit (Complete Item 14)

12. Purchase value to registrant of
Controlled Substances taken?

Yes (How many)
No

5
6
7

Pharmacy
Practitioner
Manufacturer
Hospital/Clinic

No

11. If Armed Robbery, was anyone:
Killed?

5. Principal Business of Registrant (Check one)

7 digit suffix

$

$

Yes (How many)

13. Were any pharmaceuticals or
merchandise taken?
Yes (Est. Value)
No

14. IF LOST IN TRANSIT, COMPLETE THE FOLLOWING:
A. Name of Common Carrier

B. Name of Consignee

C. Consignee’s DEA Registration Number

D. Was the carton received by the customer?

E. If received, did it appear to be tampered with?

F. Have you experienced losses in transit
from this same carrier in the past?

Yes

No

Yes

No

No

Yes (How Many ) __________

15. What identifying marks, symbols, or price codes were on the labels of these containers that would assist in identifying the products?

16. If Official Controlled Substance Order Forms (DEA-222) were stolen, give numbers.

17. What security measures have been taken to prevent future thefts or losses?

PRIVACY ACT INFORMATION
AUTHORITY: Section 301 of the Controlled Substances Act of 1970 (PL 91-513).
PURPOSE: Report theft or loss of Controlled Substances.
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 controlled substances may result in
penalties under Section 402 and 403 of the Controlled Substances Act.
FORM DEA - 106 (11-00) Previous editions obsolete

In accordance with the Paperwork Reduction Act of 1995, no person is
required to respond to a collection of information unless it displays a ly
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 30 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.

CONTINUE ON REVERSE

FORM DEA-106 (Nov. 2000) Pg. 2
Trade Name of Substance or Preparation
Examples:

LIST OF CONTROLLED SUBSTANCES LOST
Name of Controlled Substance in Preparation

Dosage Strength and Form

Desoxyn

Methamphetamine Hydrochloride

5 mg Tablets

Demerol

Meperidine Hydrochloride

50 mg/ml Vial

5 x 30 ml

Codeine Phosphate

2 mg/cc Liquid

12 Pints

Robitussin A-C

3 x 100

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I certify that the foregoing information is correct to the best of my knowledge and belief.

Signature

Quantity

Title

Date