DEA Form 106 Controlled Substance Loss Reporting

Reports theft, loss, or significant diversion of controlled substances and captures the information needed for preliminary notice and DEA Form 106 submission under 21 CFR 1301.76(b).

Submission Notice

• Incident type
• Date and time discovered
  Use the date and time the incident was first discovered. This supports the one-business-day preliminary notice requirement.
• I understand the reporting timeline requirements
  Preliminary written notice to the local DEA Field Division is due within one business day of discovery, and the electronic DEA Form 106 is due within 45 days per 21 CFR 1301.76(b).
• Anonymous submission
  Select only if your organization permits anonymous internal intake for initial triage. DEA filing and compliance follow-up may still require registrant identification.

Registrant and Facility Information

• DEA registrant name
• DEA registration number
  Enter the DEA registration number for the affected registrant.
• Facility name
• Facility address
  Provide the physical location where the controlled substance was stored, handled, or discovered missing.
• Reporter name
  Optional internal contact for follow-up. Avoid collecting unnecessary PII.
• Reporter email
  Optional contact for compliance follow-up.

Incident Details

• Date and time of incident
• Incident location
• If other, describe the location
• Incident summary
  Describe what happened, how it was discovered, and any immediate containment actions taken.
• Was law enforcement notified?
• Law enforcement details
  Include agency name, report number, and date notified if available.

Controlled Substance Inventory Impact

• Controlled substance schedule
• Product or drug name
• Dosage form
• Strength
• Quantity lost or stolen
• Unit of measure
• If other, specify unit of measure
• Have inventory records been updated?

Preliminary Notice and Investigation

• Was written preliminary notice sent to the local DEA Field Division?
• Date preliminary notice sent
• Internal investigation status
• Preliminary root cause or contributing factors
  Use objective findings only. Examples: access control gap, inventory discrepancy, shipping error, documentation error, unexplained shortage.
• Immediate corrective actions taken
  Describe containment steps, access changes, inventory reconciliation, or security measures implemented.

Certification and Submission

• Certification statement
  I certify that the information provided is true and complete to the best of my knowledge and that this report is submitted for compliance review in connection with DEA reporting obligations.
• Submitter name
• Submitter title
• Electronic signature
  Sign to confirm review and authorization to submit the report.