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Run: DEA Form 106 Controlled Substance Loss Reporting

DEA Form 106 Controlled Substance Loss Reporting captures theft, significant loss, or diversion details, the preliminary notice, and the DEA Form 106 filing ...

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Submission Notice

Report Type (required)

Why are you submitting this report? (required)

Briefly describe the reason for reporting and the circumstances that triggered discovery.

Date of Discovery (required)

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). (required)

Yes No N/A

Registrant and Location Information

DEA Registrant Name (required)

DEA Registration Number (required)

Enter the DEA registration number associated with the affected location.

Facility Name (required)

Facility Address (required)

Provide the physical location where the loss occurred or was discovered.

Facility Type (required)

Controlled Substance Details

Controlled Substance Name (required)

DEA Schedule (required)

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 (required)

Enter the number of units, bottles, vials, or other count lost.

Unit of Measure (required)

Incident Details

Where did the incident occur? (required)

Incident Description (required)

Describe what was discovered, how it was discovered, and any known circumstances.

How was the loss identified? (required)

Was law enforcement notified? (required)

Law Enforcement Agency

Police Report Number

Preliminary Notice and DEA Reporting

Preliminary notice sent to local DEA Field Division? (required)

Preliminary Notice Date

Preliminary Notice Method

Electronic DEA Form 106 submitted? (required)

DEA Form 106 Submission Date

Submission Reference Number

Corrective Actions and Review

Immediate Actions Taken (required)

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

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