Controlled Substance Inventory Form

DOH-166 (7/10) Page 1 of 1 NEW york STATE department OF health Bureau of Narcotic Enforcement Controlled Substance Inventory FORM Office Use Only Name of Person Completing Form Title Signature Controlled Substance License # Note: If the facility/program or individual is not subject to Article 33 Controlled Substance licensure, the applicable DEA registration number should be entered. LOG NUMBER _____ Name of Controlled Substance Strength/ Dosage Form Quantity or Liquid Amount Reason for Disposal/ Destruction Source of Controlled Substance Rx Number (Class 3A license holders only) mg Example: Lorazepam Tablet 40 DiscontinuedSmith Pharmacy12345671.

Controlled Substance Inventory Form Author: New York State Department of Health Subject: Controlled Substances Keywords: controlled subtance inventory form, inventory form, controlled substances, take back day, DEA Created Date: 9/14/2010 11:01:04 AM

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Health, York, Department, States, Inventory, New york state department of health, Substance, Controlled, Controlled substances

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Transcription of Controlled Substance Inventory Form

1 DOH-166 (7/10) Page 1 of 1 NEW york STATE department OF health Bureau of Narcotic Enforcement Controlled Substance Inventory FORM Office Use Only Name of Person Completing Form Title Signature Controlled Substance License # Note: If the facility/program or individual is not subject to Article 33 Controlled Substance licensure, the applicable DEA registration number should be entered. LOG NUMBER _____ Name of Controlled Substance Strength/ Dosage Form Quantity or Liquid Amount Reason for Disposal/ Destruction Source of Controlled Substance Rx Number (Class 3A license holders only) mg Example: Lorazepam Tablet 40 DiscontinuedSmith Pharmacy12345671.