DEA Form 107 Report of Loss or Disappearance of Listed Chemicals

DEA FORM

107

OMB No. 1117-0024 (Exp Date xx-xxxx) Previous editions are obsolete.

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

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

Report of Theft or Loss of Listed Chemical
New Report

Amendment Key (prior report dated):

If applicable, enter your DEA Registration Number or the Self Certify Certificate ID:
Name of Business: ___________________________________________________________________________________________________________
Address:____________________________________________________________________________________________________________________
City: ______________________________________________________________________ State: ____________ ZIP Code: _____________________
Point of Contact: ________________________________________________________________________________
Email Address:______________________________________________________________

Date of the Theft or Loss (or first discovery of theft or loss): M M D D Y Y Y Y

2.

3.

Phone No.: _______________________________

Number of Thefts and Losses in the past 24 months:_________

Principle Business of Registrant:

Pharmacy
Manufacturer
Exporter

Practitioner/MLP
Distributor
Importer

Hospital/Clinic
Teaching Institutions/Analytical Lab

Principle Business of Self Certifier:

Grocery/Superstore
Gas Station

Convenience Store
Health/Personal Care Store

Specialty Food Store
Mail Order Distributor

Merchandise/Department Store

Mobile Vendor

Other: ______________________

Type of theft or loss: (required)
Break-in/Burglary
Robbery

Employee Theft (or Suspected)
Customer Theft (or Non Employee)

Hijacking of Transport Vehicle*
Loss in Transit*

Packaging Discrepancy
Disaster (fire, weather, etc.)

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 chemicals 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 chemicals, 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.

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: _______________________________________________________

DEA FORM 107 (Date xx-xxxx) Previous editions are obsolete.

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

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DEA FORM

107

Report of Theft or Loss of Listed Chemical
OMB No. 1117-0024 (Exp Date xx-xxxx) Previous editions are obsolete.

Trade Name of Listed Chemical

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

LIST OF LISTED CHEMICALS

Chemical
Code

NDC #

DEA Transaction ID:______________________________.

Name of Listed Chemical

Package Form

Total Quantity
Lost or Stolen
(MG or KG)

Examples:
Benzaldehyde

8256

N/A

Benzaldehyde

Drum

420 KG

Sudafed® 12-Hour

8112

50580-0670-20

Pseudoephedrine

Blister-packs

28,800 MG

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Express Quantity
in
MG or KG

Enter remarks, if required. Describe how theft or loss occurred. Attach a separate sheet, if necessary:

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 107 is true and correct, and
understand that this constitutes an electronic signature for purposes of this reporting requirement only.

Signature: __________________________________________________________________ Print Name: ______________________________________________________________
Title:__________________ ______________________________________

Date Signed:_____________________________

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 30 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.

WARNING: Failure to report theft or loss of Listed Chemicals is unlawful under 21 USC 842(a)(5) and may result in penalties under 21 USC 842(c) of the
Controlled Substances Act. 21 USC 843(a)(4)(A) states that any person who knowingly or intentionally furnishes false or fraudulent information in any report is
subject to a term of imprisonment of not more than 4 years, and a fine of not more than $30,000 or both.

DEA FORM 107 (Date xx-xxxx) Previous editions are obsolete.

Privacy Act Information
AUTHORITY: Section 301 of the Controlled Substances Act of 1970 (PL 91-513).
PURPOSE: Report theft and loss of Controlled Substances.
ROUTINE USES: The Controlled Substance 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.

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