Form 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 page 1, and either page 2 or 3. 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.

2. Phone No. (Include Area Code)

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

3. DEA Registration Number

4. Date of Theft or Loss

5. Principal Business of Registrant (Check one)
1
2
3
4

6. County in which Registrant is
Located

7. Was Theft reported
to Police?


9. Number of Thefts or Losses Registrant has
Experienced in the Past 24 Months

Yes



Injured?

No
No




Pharmacy

5

Practitioner

6

Manufacturer

7





Distributor
Methadone Program
Other (Specify)

Hospital/Clinic

__________________________

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

No

1




Night Break-in

3

Armed Robbery

4




Employee Pilferage

Yes (How Many) ______________
Yes (How Many) ______________

5

Customer Theft

12. Purchase value to Registrant of
Controlled Substances taken?

11. If Armed Robbery, was Anyone:









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

2

Killed?

OMB APPROVAL
No. 1117-0001
(Expiration Date 9/30/2017)

6




Other (Explain)
Lost in Transit (Complete Item 14)

13. Were any pharmaceuticals or merchandise
taken?




$

No



Yes (Est. Value)

$

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 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 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 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 (9/30/2017) Pg. 2

Examples

Trade Name of Substance or Preparation

LIST OF CONTROLLED SUBSTANCES LOST OR STOLEN
NDC Number

Name of Controlled Substance in Preparation

Dosage Strength

Dosage Form

Total Quantity
Lost or Stolen

Desoxyn

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.
Express Quantity
in Dosage Units,
or Milliliters for
Liquids

Remarks: (Optional)

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

___________________________________________________________________
Sign and Print Name

___________________________________________________________
Title

______________________________
Date

LIST OF MAIL-BACK PACKAGES OR INNER LINERS LOST OR STOLEN

Form DEA-106 (9/30/2017) Pg. 3

Examples

Mail-Back Package

Inner Liner

X

Unique Identification Number(s)

Size of Inner Liner

Total Quantity Lost or
Stolen

N/A

5

MBP1106, MBP1108 – MBP1110, MBP1112
X

CRL1007 – CRL1027

15 GALLON

21

X

CRL1201

5 GALLON

1

1.
2
3.
4.
5.
6.
7.
8.
Express in Total
Quantities

Remarks: (Optional)

If you are an authorized Retail Pharmacy or Hospital/Clinic with an onsite Pharmacy and reporting a theft or loss at a Long-Term Care Facility (LTCF), provide name and
address of LTCF.

________________________________________________________
Name of LTCF

______________________________________________________________
Address, City, State, Zip Code

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

___________________________________________________________
Sign and Print Name

___________________________________________________
Title

__________________________
Date