Submission format

Mail Order e-Report (1117-0033).xls

Report of Mail Order Transactions

Submission format

OMB: 1117-0033

Document [xlsx]
Download: xlsx | pdf
DRUG ENFORCEMENT ADMINISTRATION (DEA) MAIL ORDER REPORT

Company Name,
Address,
Point of Contact and Telephone Number






COMPANY INFORMATION PRODUCT INFORMATION PURCHASER INFORMATION
SHIP TO INFORMATION Date Info.
Enter a unique one-up record number for each transaction. Record
Number
Enter "S" for Sales or "R" for Returns. Trans.
Type
Enter your company's DEA Registration Number. DEA
Registration
Number
Enter your company's unique identification number for this product or the NDC number for this product. Product
ID
Enter the trade name of the product (e.g., Actifed Cold and Allergy Tablets ®, Sudafed Severe Cold Caplets ®). Product Name Enter "8113" for drug products that contain EPHEDRINE, "8112" for drug products that contain PSEUDOEPHEDRINE, and "1225" for drug prodcuts that contain PHENYLPROPANOLAMINE. Chemical
Code
Enter the type (e.g., tablet, liquid, caplet) of dosage form. Dosage
Form
Enter the dosage strength in milligrams (e.g., a 60 mg tablet should be entered as "60". A 15mg/5ml liquid dose should be entered as "3"). Dosage
Strength
Enter the product amount in the package (e.g., if a bottle contains 100 tablets enter "100". If a bottle contains 4 fl. oz. enter "118.294"). Package
Size
Enter the number of packages purchased by the customer. No. of
Pkgs.
Enter the lot number of the products sold to the customer. Lot
Number
Enter only the first name of the purchaser. First
Name
Enter only the last name of the purchaser. Last
Name
Enter the street number and street name of the purchaser. Address 1 Enter additional address information of the purchaser (e.g., apt#, P.O. Box, etc.) If this information was not provided, please leave this field blank. Address 2 Enter the city name of the purchaser. City Enter the state code of the purchaser. State
Code
Enter the Zip Code of the purchaser. Do not enter a hyphen for 9 digit Zip Codes. Zip
Code

Enter only the first name to whom the product was shipped if different than the first name of the purchaser. First
Name
Enter only the last name to whom the product was shipped if different than the last name of the purchaser. Last
Name
Enter the street number and street name to where the product was shipped if different than the Address 1 of the purchaser. Address 1 Enter additional address information to where the product was shipped (e.g., apt#, P.O. Box, etc.) if different than the Address 1 of the purchaser. If this information was not provided, please leave this field blank. Address 2 Enter the city name to where the product was shipped if different than the city of the purchaser. City Enter the state code to where the product was shipped if different than the state code of the purchaser. State
Code
Enter the Zip Code to where the product was shipped if different than the Zip Code of the purchaser. Do not enter a hyphen for 9 digit Zip Codes. Zip
Code
Enter the Date the product was shipped from your company. Please Use the "MM/DD/YY" format. Date of
Shipment
File Typeapplication/vnd.ms-excel
Authorapadilla
Last Modified ByDEA
File Modified2007-03-15
File Created2004-06-01

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