Registrant Disclosure of Loss, Diversion, or Destruction ...

1 Version Registrant Disclosure of Loss, Diversion, or Destruction of Controlled Substances ( addendum to Forms dhhs 226 & 227) NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Drug Control Unit 3008 Mail Center Service Center Raleigh, North Carolina 27699-3008 (919) 733-1765 Instructions PLEASE READ THESE INSTRUCTIONS CAREFULLY This questionnaire is used to supplement information provided by a Registrant who submitted a Form dhhs 226 or 227. It is imperative that this form be completed in its entirety. Do not leave any fields blank, rather indicate that the field is not applicable by typing N/A in the space provided. This document will be used by the North Carolina Department of Health and Human Services Drug Control Unit to assist in determining whether or not the Registrant is in compliance with State and Federal laws pertaining to controlled substances.

2 Please e-mail both the completed electronic PDF and a signed PDF copy of this document to along with your Form dhhs 226 or Form dhhs 227. Failure to complete and submit this document will result in the Application for Reregistration being returned to the Registrant along with a request for additional information. Attestation By signing below, you attest that you are an administrator or an agent of the Registrant who is authorized to answer the questions presented in this document. Furthermore, you attest that all of the information provided on this form is true, accurate, and complete to the best of your knowledge. All responses are subject to verification by the North Carolina Department of Health and Human Services Drug Control Unit. Signature Date Phone Number Name & Title E-Mail Address Section A - Registrant Information Name on NC dhhs Registration NC dhhs Registration # Facility s Address Facility s County Facility s City & Zip Code Facility s Phone Number Mailing Address Mailing State, City, Zip Name on DEA Registration DEA Registration Number Administrator Name: Title: Section B - Instances of Loss, Diversion, or Destruction B1.

3 Have any individuals employed by the applicant ever been charged or convicted of a controlled substance related crime? Please explain in detail the charges/convictions and any disciplinary action taken by the individuals respective licensing board. 2 NC Department of Health and Human Services Registrant Disclosure of Loss, Diversion, or Destruction of Controlled Substances Version B2. Since the previous registration period, have there been instances in which controlled substances were either lost in transit or the Registrant experienced loss after assuming possession? If yes, please explain in detail the events that transpired, how and who the loss was reported to, and what steps have been taken since, if any, to minimize the risk of future loss. B3. Since the previous registration period, have there been any break-ins or instances of known or suspected diversion?

4 If yes, please explain in detail the events that transpired, how and who the diversion was reported to, and what steps have been taken since to establish and maintain effective controls for the prevention of future diversion. B4. Since the previous registration period, has the Registrant destroyed any controlled substance waste? In this context, the term waste refers to doses of a controlled substance that is accidentally contaminated at a nursing station or adjacent area. If yes, please explain the process employed for destroying the controlled substances and how the destructions are documented. B5. Since the previous registration period, has the Registrant destroyed any unwanted or outdated/expired controlled substances? If yes, please explain the process employed for destroying the controlled substances and how the destructions are documented.

5 Section C - Supplemental Materials Please include copies of the following documents along with this form as part of your Application for Reregistration: 1. Any and all DEA Form 106s that have been reported since the previous registration period 2. Any and all police reports filed as a result of loss or theft since the previous registration period 3. Any and all documentation of controlled substance waste that was destroyed by the Registrant within the last month 4. Any and all DEA Form 41s that have been completed since the previous registration period