Drug Box Discrepancy Report Form

Discrepancy Report Form
Please complete the following information regarding loss, theft, or tampering with any controlled substances, drug delivery devices, or other regulated medical devices from an agency, facility, or vehicle. This form should be completed as soon as possible and shall be made within 15 days of the discovered occurrence.

Reporting Party Information
Person Completing Report*

First NameMiddle NameLast NameSuffix
Title*
Agency/Business Name*
Email*
example@example.com
Phone Number*

Area CodePhone Number

Drug Box Details
EMS Incident Number
Drug Box Number*
Were any of the Drug Box Seals Broken*
Drug Box Seal #
Narcotics Drug Box Seal #
Drugs Missing From *
Vehicle/Unit Number*
If no Vehicle number please enter a license plate number
Describe Drugs Missing From "Other"*
Signs of Physical Damage*
Describe Signs of Physical Damage*
Photos of Physical Damage

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Drugs in Locked Cabinet of Box
Describe "Other"
Type of Security in Place
Describe Type of Security in Place "Other"
Date and Time Discovered*

MonthDayYear
DateHourMinutesAM/PM Option
Last Date Drugs Checked*

MonthDayYear
DateHourMinutesAM/PM Option
Last Date Box Replenished/Restocked

MonthDayYear
DateHourMinutesAM/PM Option
Name of Pharmacy to Last Replenished/Restock
Was the Drug box returned to a Pharmacy?*
Name of the Pharmacy Drug Box was returned to*
Date Box Received

MonthDayYear
DateHourMinutesAM/PM Option
List of the Drugs and Volumes Involved in the Diversion*

Parties Involved
Discovered Organization Name*
Discovered Person Name*

PrefixFirst NameMiddle NameLast NameSuffix
Discovered Person Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Discovered Person Primary Phone Number*

Area CodePhone Number
List of all Persons with Access to the Box*
Please include all persons including visitors, students, etc.
Diversion Occurred Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Law Enforcement
Has Law Enforcement Been Contacted *
Law Enforcement Agency Name*
Investigating Officer Name*

PrefixFirst NameMiddle NameLast NameSuffix
Investigating Officer Phone#*

Area CodePhone Number
Law Enforcement Report #*

Additional Pertinent Details
Any Additional Information or Comments
Any Additional Photos or Documents

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