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Run: DEA Form 106 Controlled Substance Loss Reporting

DEA Form 106 Controlled Substance Loss Reporting template for documenting theft, loss, or significant diversion and preparing the details needed for prelimin...

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Submission Notice

Incident type (required)

Date and time discovered (required)

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 (required)

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).

Yes No N/A

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.

Yes No N/A

Registrant and Facility Information

DEA registrant name (required)

DEA registration number (required)

Enter the DEA registration number for the affected registrant.

Facility name (required)

Facility address (required)

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 (required)

Incident location (required)

If other, describe the location

Incident summary (required)

Describe what happened, how it was discovered, and any immediate containment actions taken.

Was law enforcement notified? (required)

Law enforcement details

Include agency name, report number, and date notified if available.

Controlled Substance Inventory Impact

Controlled substance schedule (required)

Product or drug name (required)

Dosage form

Strength

Quantity lost or stolen (required)

Unit of measure (required)

If other, specify unit of measure

Have inventory records been updated? (required)

Preliminary Notice and Investigation

Was written preliminary notice sent to the local DEA Field Division? (required)

Date preliminary notice sent

Internal investigation status (required)

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 (required)

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.

Yes No N/A

Submitter name (required)

Submitter title

Electronic signature (required)

Sign to confirm review and authorization to submit the report.

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Email (required)

Your name (optional)

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