Article Structure
The DEA Form 106 is a crucial document for anyone involved in the handling of controlled substances, particularly when theft or loss occurs. This form serves as the official report to the Drug Enforcement Administration (DEA) and outlines details essential for addressing such incidents. Key sections of the form help registrants specify whether they are filing a new report or amending a previous submission. It collects important information such as the registrant’s DEA number, business name, and address. Additionally, the form requires reporting the type of theft or loss, the nature of the controlled substances involved, and any injuries or fatalities resulting from the incident. It's vital to specify whether the theft was reported to law enforcement and what corrective measures are already in place or have been implemented to prevent future occurrences. The detailed list of substances lost or stolen, along with their respective values, allows the DEA to assess the scale and impact of the loss accurately. Overall, completing the DEA Form 106 accurately not only aids in law enforcement efforts but also helps protect the integrity of the supply chain for controlled substances across the country.
Dea 106 Example
DEA FORM 106 |
Report of Theft or Loss of Controlled Substances |
OMB No. |
U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division
Type of Report: (check one box only) |
New Report |
Amendment Key (prior report dated): __________________________________ |
1.DEA Registration Number: _____________________________________________________
Name of Business: ___________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
City: ______________________________________________________________________ State: ____________ ZIP Code: _____________________
Point of Contact: ________________________________________________________________________________
Email Address: _____________________________________________________________ Phone No.: _______________________________
Date of the Theft or Loss (or first discovery of theft or loss): __________________________ Number of Thefts and Losses in the past 24 months: ___________
Principal Business of Registrant: Pharmacy Practitioner Manufacturer Hospital/Clinic Distributor NTP Other (Specify) __________________
2.Type of Theft or Loss: -
3.Loss in Transit. (*Fill out this section only if there was a loss in transit, or hijacking of transport vehicle.)
Name of Common Carrier: _________________________________________________________________________________________________________
Telephone Number of Common Carrier: _____________________________________ Package Tracking Number: __________________________________
Have there been losses in transit from this same carrier in the past? |
No |
Yes (If yes, how many, excluding this theft or loss?): __________ |
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Was the package received and accepted by the consignee? |
No |
Yes (If yes, the consignee is responsible for reporting the theft or loss.) |
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If the package was accepted by the consignee, did it appear to be tampered with? |
No |
Yes |
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Name of Consignee / Supplier: _________________________________________________________________________________________________________
Enter the Name of Consignee (if reported by the supplier), or the Name of Supplier (if the package was accepted by the consignee).
If the consignee does not have a DEA Registration Number, e.g. if this was a shipment to a patient, or a nursing home emergency kit, enter "Patient" or "Nursing Home Kit."
DEA Registration Number of Consignee / Supplier: _____________________________________________
Enter the DEA Registration Number of Consignee (if reported by the supplier), or DEA Registration Number of Supplier, (if the package was accepted by the consignee). If the controlled substances were shipped to a
4.If this was a robbery, were any people injured? 
No 
Yes (If yes, how many?): ______Were any people killed? 
No 
Yes (If yes, how many?): _______
5.What is the total value of the controlled substances stolen or lost?: $ _________________________________________
(This is the amount you paid for the controlled substances, not the retail value.)
6. Was theft reported to Police? |
No |
Yes (If yes, fill out the following information): |
Name of Police Department: ______________________________________________________________ Police Report number: ______________________
Name of Responding Officer: _____________________________________________________________________ Phone No.: ________________________
7.Which corrective measure(s) have you taken to prevent a future theft or loss?
Installed monitoring equipment (e.g. video camera).
Increased employee monitoring (e.g. random drug tests).
Installed metal bars or other security on doors or windows.
Secured Controlled Substances within safe.
Other (Please describe on last page).
Provided security training to staff.
Requested increased security patrols by Police.
Hired security guards for premises. 
Terminated employee.
8. Were any pharmaceuticals or merchandise taken? |
No |
Yes (Estimated Value): |
Form
DEA FORM 106 |
Report of Theft or Loss of Controlled Substances |
OMB No. |
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LIST OF CONTROLLED SUBSTANCES LOST OR STOLEN |
U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division
Examples
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Trade Name of Substance or Preparation |
NDC Number |
Name of Controlled Substance in Preparation |
Dosage Strength |
Dosage Form |
Total Quantity |
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Lost or Stolen |
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Desoxyn |
Methamphetamine Hydrochloride |
5 mg |
Tablets |
300 |
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Demerol |
Meperidine Hydrochloride |
50 mg/ml |
Vial |
150 ml |
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Robitussin |
Codeine Phosphate |
2 mg/cc |
Liquid |
5676 ml |
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Remarks: (Optional) |
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Express Quantity |
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in Dosage Units, |
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or Milliliters for |
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Liquids |
Form
DEA FORM 106 |
Report of Theft or Loss of Controlled Substances |
OMB No. |
Form |
LIST OF |
U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division
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Inner Liner |
Unique Identification Number(s) |
Size of Inner Liner |
Total Quantity Lost or |
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Stolen |
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Examples |
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X |
X |
CRL1201 |
5 GALLON |
1 |
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MBP1106, MBP1108 – MBP1110, MBP1112 |
N/A |
5 |
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X |
CRL1007 – CRL1027 |
15 GALLON |
21 |
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Remarks: (Optional) |
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Express in Total |
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Quantities |
If you are an authorized Retail Pharmacy or Hospital/Clinic with an onsite Pharmacy and reporting a theft or loss at a
________________________________________________________ |
______________________________________________________________ |
Name of LTCF |
Address, City, State, Zip Code |
Form
DEA FORM 106 |
Report of Theft or Loss of Controlled Substances |
OMB No. |
U.S. Department of Justice
Drug Enforcement Administration
Diversion Control Division
Describe any other corrective measure(s) you have taken to prevent a future theft or loss:
Enter remarks, if required. Description of how theft or loss occurred.
The foregoing information is correct to the best of my knowledge and belief: By signing my full name in the space below, I hereby certify that the foregoing information furnished on this DEA Form 106 is true and correct, and understand that this constitutes an electronic signature for purposes of this reporting requirement only.
Signature: ______________________________________________________ |
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Title: _________________________________________________________ |
Date Signed: _____________________________ |
NOTICE: In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection of information is
Freedom of Information: Please prominently identify any confidential business information per 28 CFR 16.8(c) and Exemption 4 of the Freedom of Information Act (FOIA). In the event DEA receives a FOIA request to obtain such information, DEA will give written notice to the registrant to obtain such information. DEA will give written notice to the registrant to allow an opportunity to object prior to the release of information.
Privacy Act Information
AUTHORITY: Section 301 of the Controlled Substances Act of 1970 (PL
PURPOSE: Reporting of unusual or excessive theft or loss of a Listed Chemical
ROUTINE USES: The Controlled Substances Act authorizes the production of special reports required for statistical and analytical purposes. Disclosures of information from this system are made to the following categories of users for the purposes stated:
A. Other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes.
B. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.
EFFECT: Failure to report theft or loss of Listed Chemicals may result in penalties under 21 U.S.C. § 842 and § 843 of the Federal Criminal Code.
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Form Characteristics
| Fact Name | Description |
|---|---|
| Type of Report | The DEA Form 106 is used to report the theft or loss of controlled substances. The form allows for both new reports and amendments to prior reports. |
| Governing Laws | This form is governed by federal regulations under the Controlled Substances Act, particularly 21 U.S.C. § 842 and § 843. Specific state laws may also apply. |
| Reporting Timeline | Registrants are required to report theft or loss immediately upon discovery. This ensures timely action to mitigate potential abuse. |
| Injuries in Theft | If the theft involves a robbery, reporting any injuries or fatalities is necessary. This information assists law enforcement in their investigations. |
| Implementing Security Measures | The form includes a section where businesses must outline corrective measures taken to prevent future occurrences of theft or loss, indicating a proactive approach to security. |
Guidelines on Utilizing Dea 106
Filling out the DEA 106 form is a crucial step when reporting the loss or theft of controlled substances. It requires specific information related to the incident, as well as details about your business and the substances involved. Completing this form accurately ensures that the right authorities receive the necessary information to address the situation.
- Begin by selecting the type of report you are filing (New Report or Amendment) by checking the appropriate box.
- Enter your DEA Registration Number, then fill in the name of your business.
- Provide the complete address, including city, state, and ZIP code.
- Identify a point of contact, and include an email address and phone number.
- Indicate the date of the theft or loss and the total number of thefts or losses you have experienced in the past 24 months.
- Specify the principal business type by selecting one option from the list provided.
- For the type of theft or loss, describe the details if applicable.
- If there was a loss in transit or hijacking, fill out the related section. Include the name and telephone number of the common carrier and the package tracking number.
- Indicate any past losses associated with the same carrier and whether the consignee accepted the package.
- Complete the section about the consignee or supplier, including their DEA Registration Number if applicable.
- If the incident involved a robbery, state whether any people were injured or killed, along with the number of individuals affected.
- Report the total value of the controlled substances that were stolen or lost.
- Confirm whether the theft was reported to the police and provide the name of the police department and any relevant report number.
- List the corrective measures you have taken to prevent future thefts or losses.
- State whether any pharmaceuticals or merchandise were taken. If yes, provide an estimated value.
- Complete the list of controlled substances lost or stolen, including their trade names, NDC numbers, and total quantities lost or stolen.
- If applicable, fill out details for any mail-back packages or inner liners lost or stolen.
- Provide the name and address of the Long-Term Care Facility if relevant.
- Describe any corrective measures taken and provide any additional remarks.
- Sign the form with your full name, assuring that the information provided is accurate.
- Include your title and the date you signed the form.
What You Should Know About This Form
What is the DEA Form 106 used for?
The DEA Form 106 is designed to report the theft or loss of controlled substances. If your organization manages or handles controlled substances and experiences such an incident, it's important to fill out this form. Reporting ensures that the Drug Enforcement Administration (DEA) is aware of potential risks and can take appropriate action. The data collected helps in tracking trends, locating stolen controlled substances, and preventing future thefts.
How do I complete the DEA Form 106?
To complete the DEA Form 106, you'll start by determining the type of report you're filing, either a new report or an amendment. Fill in details like your DEA registration number, business name, and contact information.
Next, indicate the date of the theft or loss, and describe what happened. If there was a loss during transit, provide information about the common carrier. Be sure to include any involvement of law enforcement, such as a police report number. Lastly, consider any corrective measures you've taken to prevent future incidents and list them on the form.
Do I need to notify the police if there's a theft?
Yes, it's crucial to alert local law enforcement if you experience a theft. In fact, when filling out the DEA Form 106, you will be asked whether you reported the theft to the police. If you did notify them, you’ll need to provide details, including the name of the police department and the report number. Reporting to law enforcement not only helps in recovering the stolen substances but also creates an official record of the event.
What happens if I don’t report a theft or loss?
Failing to report a theft or loss of controlled substances may lead to serious consequences. The DEA requires all registrants to report such incidents, and not doing so can result in penalties under the federal laws governing controlled substances. Furthermore, unreported losses may encourage further thefts and put the public at risk. By reporting, you help create a safer environment for all.
Common mistakes
Filling out the DEA Form 106 is a critical process that requires attention to detail. Mistakes can lead to delays or complications, jeopardizing compliance and safety. Here are eight common errors people make when completing this form.
1. Incomplete Registration Information: One of the most common mistakes is failing to fill in the DEA registration number correctly. This number is essential for identifying the reporting party. Omitting or misreporting it can cause significant issues in processing the report.
2. Missing Contact Details: Any lack of information regarding the point of contact can complicate communication with the DEA. It’s important to provide a direct contact person's name, phone number, and email address to ensure that the DEA can reach out easily for any follow-ups.
3. Incorrect Theft or Loss Date: People often enter the wrong date for when the theft or loss occurred. This error can lead to confusion in tracking the incident and may impact investigations or compliance audits.
4. Inadequate Description of the Incident: If the description of how the theft or loss occurred is vague or incomplete, the DEA may struggle to understand the situation fully. Providing a thorough account helps ensure all relevant details are considered.
5. Failing to Report to Police: Some individuals do not report the theft or loss to law enforcement, which is a crucial step. If the police report is missing or incomplete, it can hinder further investigations and indicate a lack of due diligence.
6. Misrepresenting the Value: Incorrectly reporting the value of the stolen substances is a common pitfall. It’s vital to state the correct amount paid for the substances, as misrepresentation can lead to compliance issues and potential penalties.
7. Omitted Security Measures: Not detailing what measures have been taken post-incident to prevent future occurrences can reflect poorly on the reporting entity. Highlighting corrective actions demonstrates proactive behavior in maintaining security.
8. Neglecting to Sign the Form: Finally, failing to sign the DEA Form 106 can invalidate the report. The signature confirms the accuracy of the information provided and is a vital part of the submission process.
By avoiding these common mistakes, individuals can ensure that their DEA Form 106 is accurate and compliant, facilitating a smoother reporting process.
Documents used along the form
The DEA 106 form is essential for reporting the theft or loss of controlled substances. In conjunction with this form, several other documents may be necessary to provide a comprehensive report. Below is a summary of some commonly used forms and documents that complement the DEA 106.
- DEA Form 41: This form is used for the disposal of controlled substances. If any controlled substances are lost or stolen, they may need to be disposed of according to established regulations.
- DEA Form 363: This is used by treatment programs for the registration and operation of narcotic treatment programs. It is particularly relevant for facilities that handle controlled substances in a treatment context.
- Police Report: A record generated by law enforcement after a theft or loss incident. It provides official documentation of the incident and can be referenced in the DEA 106 form.
- Inventory Records: These records detail the quantities and types of controlled substances held by a business. They are important for tracking losses and are often compared against the findings in the DEA 106.
- Security Measures Documentation: This includes records related to security protocols and measures taken to prevent future thefts. It may include details on equipment like cameras or alarms and training provided to staff.
Utilizing these documents in conjunction with the DEA 106 form helps ensure accurate reporting and compliance with federal regulations regarding controlled substances. Proper documentation enhances accountability and aids in minimizing future incidents.
Similar forms
- DEA Form 222: This form is used for ordering controlled substances. Like the DEA 106, it requires detailed information about the substances involved, including the name, quantity, and registered business details. Both forms ensure compliance and accountability in handling controlled substances, although DEA Form 222 is specifically about ordering, while DEA 106 pertains to reporting theft or loss.
- Form FDA 3500A: This form is associated with reporting adverse events related to pharmaceuticals and medical devices. Similar to DEA Form 106, it collects vital information that helps in monitoring public safety. Both forms require the identification of the substances involved and detailed descriptions, ensuring that authorities are informed of issues that may affect public health.
- PHS-7002: This is the form used to report a loss of controlled substances in the Public Health Service. Like the DEA 106, it serves a similar purpose of notifying authorities about loss or theft, providing necessary details about the substances and circumstances. It is a compliance measure to maintain a secure environment for controlled substances.
- OSHA Incident Report (Form 301): This form is used to report workplace injuries or illnesses. While it differs in focus, the process of documenting incidents is analogous to the DEA 106. Both forms require specific details regarding the event, including time, location, and people involved, ensuring proper follow-up and investigation into the circumstances surrounding an event.
Dos and Don'ts
When filling out the DEA Form 106, there are certain best practices to follow and some common pitfalls to avoid. Here’s a simple list to help guide you:
- Do ensure all information is accurate and complete to avoid delays.
- Do provide contact information for a reliable point of contact.
- Do state clearly the type of theft or loss that occurred.
- Do report any thefts or losses to the police immediately.
- Do keep copies of the completed form for your records.
- Don’t leave any required fields blank; this could slow down the process.
- Don’t provide estimated values for lost substances; use the amount you paid.
- Don’t forget to describe how the theft or loss occurred in detail.
- Don’t assume the recipient of a shipment is aware of any theft; proactively inform them.
Misconceptions
- Misconception 1: The DEA 106 form is only required for major incidents of theft or loss.
- Misconception 2: Only pharmacies are required to submit the DEA 106 form.
- Misconception 3: Reporting a theft of controlled substances is optional.
- Misconception 4: The value reported on the DEA 106 form should reflect the retail price of the stolen substances.
- Misconception 5: Once the DEA 106 form is submitted, no further action is required.
This form is necessary for any theft or loss of controlled substances, regardless of the scale. Even minor losses need to be reported to ensure compliance and adequate tracking of controlled substances.
Any entity that handles controlled substances, including hospitals, clinics, manufacturers, and distributors, must file the DEA 106 form if they experience a theft or loss. The requirement is not limited to pharmacies.
Filing the DEA 106 form is mandatory under federal regulations. Failure to report can lead to legal penalties and compliance issues.
The form instructs users to report only the amount paid for the controlled substances, not their retail value. This distinction is crucial for accurate reporting.
After submitting the form, entities should also implement corrective measures to prevent future thefts or losses. Additionally, follow up with local law enforcement if applicable, as detailed reporting may be necessary.
Key takeaways
Filling out the DEA 106 form requires careful attention to detail to ensure accurate reporting of theft or loss of controlled substances. Here are key takeaways to consider:
- Understand the Purpose: The DEA 106 form is specifically designed to report any theft or loss of controlled substances. All businesses handling these substances must use this form to comply with federal regulations.
- Complete Required Sections: Essential information must be filled out accurately, including the DEA registration number and details about the business. The report should specify the type of report, whether it is a new report or an amendment.
- Detail the Loss: It is crucial to provide detailed accounts of the theft or loss, including the date it occurred, how it happened, and whether any individuals were injured. This information aids in investigations and future prevention efforts.
- List Controlled Substances: A specific section requires the identification of lost or stolen substances, including their trade names, quantities, and NDC numbers, allowing the DEA to track these materials effectively.
- Take Corrective Actions: The form includes a section where businesses should outline any measures taken to prevent future incidents. This can demonstrate due diligence and commitment to security.
By understanding and carefully following these guidelines, individuals can ensure that they fulfill their reporting obligations effectively while helping to enhance the safety and security of controlled substances.
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