Information Request Form

Please provide Company Information* This field is required.All fields are Required

What is your primary type of DEA Registration that you have or will you have?* This field is required.

Upload your most recent Inventory ReportNot More Than 2 pages...

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Max. file size: 10.6MB

Upload an example of a DEA "Incoming" drug report. Showing how much of the drug was "RECEIVED" by your company during the audit period* This field is required.Typically includes: Purchases, Transfers from Related Companies, Donations, samples, etc.

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Max. file size: 10.6MB

Common Incoming: Purchases, Transfers from Related DEA #s, etc...

Upload a DEA Report Showing OUTGOING (drugs) went out of your facility.* This field is required.Typically includes: Dispensations, Distributions (Sales), Destruction/Disposal, Donated, Returned to Manufacturers, etc.

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Max. file size: 10.6MB

Common Outgoing: Sales to other DEA holders (Distributions), Dispensations, Transfers to Related DEA #s, Destruction/Disposals, etc...

Great job...Let's focus on Security. Upload a Copy of your most recent alarm test conducted. Include a legend/zone sheet* This field is required.During the Audit Period

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Max. file size: 10.6MB

Upload a copy of your Floorplan...Highlight areas where CS are stored. Also indicate type of storage container being used in each area to store CS.* This field is required.During the Audit Period

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Max. file size: 10.6MB

Storage: Cabinet, Safe, Cage, Vault, etc...

When was your last inventory taken?* This field is required.

Within 2 years

More than 2 years ago

Never

Type option 4

Inventory is a physical count of controlled substances. Provide the date that the most recent inventory taken?

Date

What time of day was the inventory taken?

Beginning of Business (BOB)Close of Business (COB)

Inventory has been uploaded* This field is required.(If no inventory has been taken select "False")

TrueFalse

As an example, we will be inventorying the fastest moving controlled substances within your business?* This field is required.Describe the Drug: Include Drug Name, Strength, and Form (ie: Hydrocodone 10/325mg tablets)

We need to know how much of that drug that you currently have on-hand. Take a physical count of that drug and list the amount below.* This field is required.Describe in terms of mgs, tabs, vials, etc. (ie: 2000 tablets) or (2000 mgs) "Be consistent with the metrics used"

Remember: include stock, warehouses, LTCF, ADS machines, throughout the pharmacy,

What date did you take the count of the amount currently in your possession?* This field is required.

Date

What time of day was the current on-hand count taken?* This field is required.

Beginning of Business (BOB)Close of Business (COB)

Audit PeriodBased on the period when the inventory was taken through the date that you took the physical current count.

We need to know what type(s) of transactions were used to move the drug into your facility. Select all that apply.INCOMING

Purchased from another DEA Registrant

Donated In

Transferred from Related Company

Returned from Customer

Returned from a Patient(s)

Other In's

Provide a list of suppliers that were used during the audit period to procure all quantities of that drug.* This field is required.Include: Name of Provider, DEA #, Address, & Contact Information. Click the "plus" button to Add as many as needed

We need to know what type(s) of transactions were used to move the drug out of your facility. Select all that apply.OUTGOING

Destroyed Onsite

Dispensed

Disposed of it by Reverse Distributor

Distributed (Sold to another registrant)

Donated Out

Returned to Vendor

Other

Provide the name of each Vendor used to remove the Drug from your facility * This field is required.Include: Name of Provider, DEA #, Address, & Contact Information. Click the "plus" button to Add as many as needed

Do you handle Thiafentanil, Carfentanil, Etorphine Hydrochloride or Diprenorphine

YESNO

Controlled Substances are stored in various containers. Please select all the storage areas used by your company for that drug (only).Select ALL that apply

securely locked, substantially constructed cabinet

disperse such substances throughout the stock of noncontrolled substances

securely locked room with controlled access for "mail-back packaging"

safe or steel cabinet equivalent to a U.S. Government Class V security container

safe or steel cabinet

vault constructed before, or under construction on, September 1, 1971

A vault constructed after September 1, 1971

building

cage, located within a building on the premises

cage, located outside a building on the premises

enclosure of masonry or other material, approved in writing by the Administrator

other

Final Calculation