DEA Form 106 Controlled Substance Loss Reporting

Reports theft, significant loss, or diversion of controlled substances and documents the required preliminary notice and DEA Form 106 submission timeline.

Submission Notice

• Report Type
• Why are you submitting this report?
  Briefly describe the reason for reporting and the circumstances that triggered discovery.
• Date of Discovery
  Use the date the theft, loss, or diversion was first discovered.
• Time of Discovery
• I understand the preliminary notice must be sent to the local DEA Field Division within one business day of discovery and DEA Form 106 must be filed electronically within 45 days, per 21 CFR 1301.76(b).

Registrant and Location Information

• DEA Registrant Name
• DEA Registration Number
  Enter the DEA registration number associated with the affected location.
• Facility Name
• Facility Address
  Provide the physical location where the loss occurred or was discovered.
• Facility Type

Controlled Substance Details

• Controlled Substance Name
• DEA Schedule
• Dosage Form
  Examples: tablet, capsule, vial, patch, solution.
• Strength / Concentration
  Examples: 10 mg, 5 mg/mL, 0.1 mg/hr.
• Package Size
  Examples: 100 tablets per bottle, 10 mL vial.
• Quantity Lost
  Enter the number of units, bottles, vials, or other count lost.
• Unit of Measure

Incident Details

• Where did the incident occur?
• Incident Description
  Describe what was discovered, how it was discovered, and any known circumstances.
• How was the loss identified?
• Was law enforcement notified?
• Law Enforcement Agency
• Police Report Number

Preliminary Notice and DEA Reporting

• Preliminary notice sent to local DEA Field Division?
• Preliminary Notice Date
• Preliminary Notice Method
• Electronic DEA Form 106 submitted?
• DEA Form 106 Submission Date
• Submission Reference Number

Corrective Actions and Review

• Immediate Actions Taken
• Corrective Action Summary
  Summarize process changes, access controls, or follow-up actions to reduce recurrence.
• Root Cause Category
• Reviewed By
  Enter the name or role of the compliance reviewer. Avoid unnecessary PII.
• Review Date