Diversion Control Division, US Department of Justice, Drug Enforcement Administration

Pharmacist's Manual - APPENDIX A-N

Appendix I

Guidelines for Completing the DEA Form 106

Instructions for completing the DEA Form 106 are provided when filling out either the paper or electronic version of the form. Listed below are additional guidelines:

  • Do not use a DEA Form 106 to report an accidental spillage. Save the broken bottles, salvage the product if possible, and contact the local DEA Diversion Field Office (Appendix K) for additional instructions.  This type of a loss must be reported on a DEA Form 41, Registrants Inventory of Drugs Surrendered.
  • If thefts have occurred due to employee pilferage over a period of time, document on the DEA Form 106 the date of discovery in block 4. Provide estimated beginning and ending dates of the thefts in box 17 with an explanation.
  • If there are multiple thefts or losses on the same day (e.g. mail-order pharmacy), report each theft or loss on a separate DEA Form 106.
  • Miscounts or adjustments to inventory involving clerical errors on the part of the pharmacy should not be reported on a DEA Form 106. A separate log documenting the discrepancies may be kept at the management’s discretion.
  • In block 9, enter the number of thefts or losses experienced in the last 24 months, but do not include the current theft or loss being reported. If the current theft or loss was the only theft or loss in the last 24 months, enter 0 (zero).
  • In block 12, enter the amount the pharmacy paid for the controlled substances, not the retail value.
  • In blocks 14 b & c, if the customer accepted the controlled substance before discovering a loss in transit, identify the supplier and its DEA registration number.
  • In block 14f, when explaining how many losses occurred from the same carrier, do not include the current loss.
  • The date next to the signature and title on page 2 should be the date the form was completed, signed, and sent to the local DEA Diversion Field Office (Appendix K).
  • Document the National Drug Code (NDC) number of the controlled substance, and if the loss was a partial container, document the actual amount of theft or loss within the container.
  • If the controlled substance contains hydrocodone, oxycodone or a similar controlled substance and contains acetaminophen, aspirin or ibuprofen, indicate the strength of the non-controlled substance as well as the strength of the controlled substance contained in the product.
  • If amending a paper version of a prior DEA Form 106, print Amended in the upper front page margin, with the date of the theft.

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