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

DEA FORM

106

Report of Theft or Loss of Controlled Substances

Type of Report: (check one box only)
1.

OMB No. 1117-0001 (Exp. Date TBD)

New Report

U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division

Amendment Key (prior report dated): __________________________________

DEA Registration Number: _____________________________________________________
Name of Business: ___________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
City: ______________________________________________________________________ State: ____________ ZIP Code: _____________________
Point of Contact: ________________________________________________________________________________
Email Address: _____________________________________________________________

Phone No.: _______________________________

Date of the Theft or Loss (or first discovery of theft or loss): __________________________ Number of Thefts and Losses in the past 24 months: ___________
Principal Business of Registrant: Pharmacy Practitioner Manufacturer Hospital/Clinic Distributor NTP Other (Specify) __________________
If "OTHER", please specify:

2.

Type of Theft or Loss: -

3.

Loss in Transit. (*Fill out this section only if there was a loss in transit, or hijacking of transport vehicle.)
Name of Common Carrier: _________________________________________________________________________________________________________
Telephone Number of Common Carrier: _____________________________________ Package Tracking Number: __________________________________
Have there been losses in transit from this same carrier in the past?
No
Was the package received and accepted by the consignee?
No
If the package was accepted by the consignee, did it appear to be tampered with?

Yes (If yes, how many, excluding this theft or loss?): __________
Yes (If yes, the consignee is responsible for reporting the theft or loss.)
No
Yes

Name of Consignee / Supplier: _________________________________________________________________________________________________________
Enter the Name of Consignee (if reported by the supplier), or the Name of Supplier (if the package was accepted by the consignee).
If the consignee does not have a DEA Registration Number, e.g. if this was a shipment to a patient, or a nursing home emergency kit, enter "Patient" or "Nursing Home Kit."

DEA Registration Number of Consignee / Supplier: _____________________________________________
Enter the DEA Registration Number of Consignee (if reported by the supplier), or DEA Registration Number of Supplier, (if the package was accepted by the consignee). If the
controlled substances were shipped to a non-registrant, leave blank, unless a registered pharmacy shipped to an emergency kit held on site at a nursing home. In this case, the
supplying pharmacy is required to report the theft or loss.

4.

If this was a robbery, were any people injured?

5.

What is the total value of the controlled substances stolen or lost?: $ _________________________________________

6.

Was theft reported to Police?

No

Yes (If yes, how many?): ______Were any people killed?

No

Yes (If yes, how many?): _______

(This is the amount you paid for the controlled substances, not the retail value.)

No

Yes (If yes, fill out the following information):

Name of Police Department: ______________________________________________________________ Police Report number: ______________________
Name of Responding Officer: _____________________________________________________________________ Phone No.: ________________________
7.

8.

Which corrective measure(s) have you taken to prevent a future theft or loss?
Installed monitoring equipment (e.g. video camera).
Increased employee monitoring (e.g. random drug tests).
Installed metal bars or other security on doors or windows.
Secured Controlled Substances within safe.
Other (Please describe on last page).
Were any pharmaceuticals or merchandise taken?

Form DEA-106 (TBD) Pg. 1

No

Provided security training to staff.
Requested increased security patrols by Police.
Hired security guards for premises.
Terminated employee.

Yes (Estimated Value):

DEA FORM

106

Report of Theft or Loss of Controlled Substances

U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division

OMB No. 1117-0001 (Exp. Date TBD)

LIST OF CONTROLLED SUBSTANCES LOST OR STOLEN
Examples

Trade Name of Substance or Preparation

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

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Remarks: (Optional)

Form DEA-106 (TBD) Pg. 2

Express Quantity
in Dosage Units,
or Milliliters for
Liquids

DEA FORM

106

Report of Theft or Loss of Controlled Substances
OMB No. 1117-0001 (Exp. Date TBD)

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

Form DEA-106 (10/23/2020) Pg. 3

Examples

Mail-Back Package

U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division

Inner Liner

X

Unique Identification Number(s)

MBP1106, MBP1108 – MBP1110, MBP1112

Size of Inner Liner

Total Quantity Lost or
Stolen

N/A

5

X

CRL1007 – CRL1027

15 GALLON

21

X

CRL1201

5 GALLON

1

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Remarks: (Optional)

Express in Total
Quantities

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

Form DEA-106 (TBD) Pg. 3

______________________________________________________________
Address, City, State, Zip Code

DEA FORM

106

Report of Theft or Loss of Controlled Substances
OMB No. 1117-0001 (Exp. Date TBD)

U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division

Describe any other corrective measure(s) you have taken to prevent a future theft or loss:

Enter remarks, if required. Description of how theft or loss occurred.

The foregoing information is correct to the best of my knowledge and belief: By signing my full name in the space below, I hereby certify that the foregoing information furnished
on this DEA Form 106 is true and correct, and understand that this constitutes an electronic signature for purposes of this reporting requirement only.

Signature: ______________________________________________________
Title: _________________________________________________________

NOTICE: 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.

Date Signed: _____________________________

Privacy Act Information
AUTHORITY: Section 301 of the Controlled Substances Act of 1970 (PL 91-513)
PURPOSE: Reporting of unusual or excessive theft or loss of a Listed Chemical
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 Listed Chemicals may result in penalties under 21
U.S.C. § 842 and § 843 of the Federal Criminal Code.

Form DEA-106 (TBD) Pg. 4