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

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. Complete the front and back of this form. Make two additional copies of the completed form.
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)

OMB APPROVAL
No. 1117-0001
(Expiration Date 00/00/0000)

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

3. DEA Registration Number

4. Date of Theft or Loss

2 ltr. prefix

1
2
3
4

7. Was Theft reported
to Police?

6. County in which Registrant is
located

Yes

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

No

Injured?

Distributor
Methadone Program
Other (Specify)

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

No

1

Night break-in

3

Employee pilferage
l

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

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

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

In accordance with the Paperwork Reduction Act of 1995, no person is
required to respond to a collection of information unless it displays a
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 20 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.
Freedom of Information: Please prominently identify any confidential
business information per 28 CFR 16.8(c) and Exemption 4 of the Freedom of
Information Act (FOIA). In the event DEA receives a FOIA request to obtain
such information, DEA will give written notice to the registrant to allow an
opportunity to object prior to the release of information.
CONTINUE ON REVERSE

FORM DEA-106 (August 2008) Pg. 2
Trade Name of Substance or Preparation
Examples

Desoxyn

LIST OF CONTROLLED SUBSTANCES LOST
NDC Number

Name of Controlled Substance in Preparation

Dosage Strength

Dosage Form

Total Quantity
Lost or Stolen

00074-3377-01

Methamphetamine Hydrochloride

5 mg

Tablets

300

Demerol

00409-1181-30

Meperidine Hydrochloride

50 mg/ml

Vial

150 ml

Robitussin A-C

00031-8674-25

Codeine Phosphate

2 mg/cc

Liquid

5676 ml

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Express Quantity
in Dosage Units
or Milliliters
for Liquids

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

Sign and Print Name

Title

Date