Due-Diligence Questionnaire

1301 NW 84th Avenue, Suite 101A Miami, Florida 33126

(800) 399-VETS (8387) Fax:(866) 421-5269

DEA REGISTRATION INFORMATION

Customer type:

Veterinary Veterinary Surgery Center Humane Society

DEA Registrant Name

DEA Registration Number

DEA Registration Schedule

2 2N 3 3N 4 5

DEA Registration Number Exp. Date

DEA Registration Address

REGISTERED STATE LICENSES / REGISTRATIONS

	STATE	LIC #	TYPE	EXP
1
2
3
4
5

BUSINESS INFORMATION

Business type

Sole Proprietor Partnership Corporation

State of Incorporation

Corporate Officers

Name

DBA

Address

Phone

Fax

Number of Employees

Business Hours

Years in Business

Veterinary. Director / 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?If yes, attach separate explanation of results and any corrective action.)

Yes No

If yes, attach separate explanation of results and any corrective action.

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

Yes No

If yes, attach explanation

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

Yes No

If yes, attach explanation

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

Yes No

Is access to the controlled substances limited?

Yes No

How many employees have access to controlled substances?

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

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).

Yes No

List the top three most commonly dispensed/administered controlled substances

List the top three most commonly prescribed controlled substances

How often are controlled substances ordered?

Daily Weekly Monthly Other

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

Yes No

Does the facility have a contract with a Reverse Distributor?

Yes No

If yes, please provide the name and DEA Registration

Signature of DEA Registrant

Clear

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

Clear

FACILITY PHOTOS INTERIOR

Browse Files

FACILITY PHOTOS EXTERIOR

Browse Files

FACILITY PHOTOS SECURITY

Browse Files

Required Documentation

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 )