Due-Diligence Questionnaire

Click Here for Due-Diligence Quick Guide

(To access Quick Guide - login to website)

DEA REGISTRATION INFORMATION

Customer type: (Select all that apply)*

DEA Registrant Name:*

DEA Registration Number:*

DEA Registration Schedules: (Check all that apply)*

IIIIIIVV

DEA Registration Expiration Date:*

Date

DEA Registration Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Registered State Licenses & Registrations: (DVM, DEA, HCCE, etc.) *

BUSINESS INFORMATION

Business type:*

Sole ProprietorPartnershipCorporation

State of Incorporation:*

Corporate Officers: *

Business Name:*

Does your business have a DBA?*

YesNo

Provide the DBA*

Is the DEA Registration address the same as the business address?*

YesNo

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Number of Employees: *

Business Phone Number:*

Area CodePhone Number

Business Hours*

i.e. 24 hours or 9:00am - 5:00pm

Number of Years in Business: *

Upload the DVM License:*

Browse Files

Upload the DEA Registration:*

Browse Files

Name of Veterinary practitioner(s) responsible & authorized for Controlled Substance Purchases:*

Has any registrant at this location been inspected by any licensing authority, including DEA, in the past 5 years?*

YesNo

Provide explanation of results and any corrective action:*

Is any registrant or any practitioner/employee currently under investigation by any licensing authority, including DEA?*

YesNo

Provide explanation of current investigation and status:*

Has registrant or any practitioner/employee had a license or registration denied, revoked, or suspended by any licensing authority, including DEA?*

YesNo

Provide explanation of what occurred with this license or registration and current status: *

Use N/A if none.

Does the storage location meet the security requirements of 21 CFR §1301.75(b)?*

YesNo

Is access to the controlled substances limited?*

YesNo

How many employees have access to controlled substances?*

Name(s) of employee(s) responsible for controlled substance purchasing, reporting, record-keeping, security:*

Separate by commas ","

Is any employee authorized to sign on behalf of the hospital DEA Registrant?*

YesNo

Name of Employee Authorized to sign on behalf of the hospital DEA Registrant:*

First NameLast Name

Does employee authorized to sign DEA forms 222 have a valid Power of Attorney on file at the registered location?*

YesNo

Submit Power of Attorney here: *

Browse Files

List the top three most commonly dispensed & administered controlled substances: *

Separate by commas ","

List the top three most commonly prescribed controlled substances: *

Separate by commas ","

How often are controlled substances ordered?*

DailyWeeklyMonthlyOther

Do you sell or transfer controlled substances to any other registrant?*

YesNo

Does the facility have a contract with a Reverse Distributor?*

YesNo

Provide the name and DEA Registration of Reverse Distributor:*

Your Email:*

example@example.com

Signature of DEA Registrant*

Signature of Employee(s) responsible for controlled substance purchasing, reporting, record-keeping, security*

ALL PHOTOS BELOW MUST BE SUBMITTED BEFORE YOUR DUE-DILIGENCE FORM IS APPROVED.

FACILITY PHOTOS INTERIOR*

Browse Files

Formats Accepted: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

FACILITY PHOTOS EXTERIOR*

Browse Files

Formats Accepted: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

FACILITY PHOTOS SECURITY*

Browse Files

Formats Accepted: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

Required Documentation

Click Here for Due-Diligence Quick Guide

Completed questionnaire.
DEA and State Controlled Substance Registration.
Any Letters of Admonition, Orders to Show Cause or Memorandum of Agreement with the DEA that are currently in effect or issued in the previous 5 years. Include any responses to these letters/documents.
Disciplinary documents from local, state, or federal agencies.
Copies of all DEA Form 106 submitted to the DEA in the prior 36 months
Photographs of the interior and exterior of the facility and security features.
Copies of any Power of Attorney documents in effect over the DEA Controlled Substance Registration.

Thank you for completing the Amatheon Animal Health “Know Your Customer” Due Diligence Form. This allows Amatheon to obtain the necessary data to reasonably review your controlled substance purchases and to assist your hospital in protecting its own regulatory interests.

The Code of Federal Regulations, 21CFR Part 1301.74(b) requires distributors of controlled substances to design and operate a system to identify suspicious orders. Suspicious orders may include those of unusual size, deviating substantially from a normal historical pattern, and/or orders of unusual frequency.

(Reference https://www.deadiversion.usdoj.gov/21cfr/cfr/1301/1301_74.htm )

Customer type:*

Phone*

DEA Registration Schedule*

DEA Registration Number Exp. Date*

Does employee authorized to sign DEA forms 222 have a valid Power of Attorney on file at the registered location? (If Yes, please provide copies of Power of Attorney).*

YesNo

Name of Employee Authorized to sign on behalf of the hospital DEA Registrant:*

First NameLast Name

DEA Registration Address*

Address*

How many employees have access to controlled substances?*

Are any employees authorized to sign on behalf of the hospital DEA Registrant?*

YesNo

Number of Years in Business:*

Number of Employees*

Fax*

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