SENTRY User Registration Form

OMB Control Number 1105-0087
Expiration Date December 2013

USER REGISTRATION FORM

Date: _____________________

Name: __________________________________________________________________________
First

Middle

Last

Organization: ____________________________________________________________________
Title/Position: ______________________________ *Role: ________________________________
Physical Address: _________________________________________________________________
(No PO Box)

Street

City

State

Zip code

Phone: ________________________________ Fax: _____________________________________
Email Address: ___________________________________________________________________
Security Question (choose only ONE question):
1. In what town was your first job? _________________________________________________
2. What is your favorite pet’s name? ________________________________________________
3. What is the name of your elementary school? _______________________________________
Signature: _______________________________________________________________________
Where did you hear about SENTRY?________________________________________________
*Role:
Analyst
Chemist
Treat provider specializing in drug abuse issues
Education provider (teacher administrator, school resource officer, school nurse)
Law enforcement officer
Medical personnel (physician, nurse, emergency medical technician, medical examiner)
Other (please explain)
FAX THIS FORM TO: 814-532-5858

ALL FIELDS REQUIRED
Paperwork Reduction Act Notice - A person is not required to respond to a collection of information unless it displays a valid OMB control number. The SENTRY user registration form is the first step toward the collection
of information related to emerging issues related to the abuse, availability, transportation, and/or distribution of synthetic drugs such as LSD (lysergic acid diethylamide), MDMA (3,4-methylenedioxymethamphetamine,
also known as ecstasy), and methamphetamine. SENTRY also is intended to monitor prescription drugs, over-the-counter medications, botanical substances and extracts, and chemicals and products involved in the
manufacturing of synthetic drugs. The information requested in voluntary.
The estimated average burden associated with completing the user registration form is 5 minutes. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed
to the Collection Management Group, National Drug Intelligence Center, 319 Washington Street, 5th Floor, Johnstown, PA 15901, or at (800) 624-4958.

01/04/2011