Controlled Substances Inspection Form
To be utilized for beginning of tour inspection.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Which tour is this being completed during?
*
Please Select
06:00-18:00
18:00-06:00
Which safe is controlled substance case being inspected from?
*
Please Select
1599
155
156
Stock Room
Integrity of Seal
*
Please Select
Intact
Broken
Seal Number
Old Seal Number (If missing type 0)
New Seal Number
Contents of controlled substance case.
*
Rows
Zero
One
Two
Midazolam
Morphine
Fentanyl
Picture of contents of controlled substance case with broken seal.
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