Revised form DEA-106

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.

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.

OMB APPROVAL

No. 1117-0001

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 5. Principal Business of Registrant (Check one)

2 Itr. prefix 7 digit suffix 1 0 Pharmacy 5 0 Distributor

2 0 Practitioner 6 Q Methadone Program

3 Q Manufacturer 7 Q Other (Specify)

4 0 Hospital/Clinic

6. County in which Registrant is

located

7. Was Theft reported 8. Name and Telephone Number of Police Department ( Include Area Code)

to Police?

Q Yes Q No

9. Number of Thefts or Losses Registrant 10. Type of Theft or Loss (Check one and complete items below as appropriate)

has experienced in the past 24 months

1 0 Night break-in 3 0 Employee pilferage 5 Q Other (Explain)

2 Q Armed robbery 4 0 Customer theft 6 Q Lost in transit (Complete Item 14)

11. If Armed Robbery, was anyone : 12. Purchase value to registrant of 13. Were any pharmaceuticals or

Controlled Substances taken ? merchandise taken?

Killed? Q No 0 Yes ( How many) No Q Yes (Est. Value)

Injured? 0 No Q Yes (How many) $ $

14. IF LOST IN TRANSIT, COMPLETE THE FOLLOWING:

A. Name of Common Carrier

D. Was the carton received by the customer?

LlYes Q No

B. Name of Consignee

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

L Yes 0 No

C. Consignee's DEA Registration Number

F. Have you experienced losses in transit

from this same carrier in the past?

0 No 0 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.

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.

FORM DEA - 106 (11-00) Previous editions obsolete CONTINUE ON REVERSE