Controlled Substances Tracking Form
To be utilized for any controlled substance administration, breakage and/or waste.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Time
*
Hour Minutes
AM
PM
AM/PM Option
Which vehicle safe is controlled substance case from?
*
Please Select
1599
155
156
Purpose of this form completion?
*
Please Select
Medication Administration and Waste
Medication Administration
Medication Waste
Medication Breakage
What medication was used, broken and/or wasted?
*
Please Select
Morphine
Fentanyl
Midazolam
Amount administered?
Amount wasted?
Amount of breakage?
Old Seal
*
New Seal
*
Circumstances surrounding administration, waste and/or breakage. If applicable, include run number and brief reasoning behind administration, waste and/or breakage.
*
Signature
*
Submit
Should be Empty: