Controlled Dangerous Substance Registration - New Jersey Division of ...

New Jersey Office of the Attorney General

Division of Consumer Affairs Drug Control Unit

124 Halsey Street, 6th Floor, P.O. Box 45045, Newark, NJ 07101 (973) 504-6351

Controlled Dangerous Substance Registration

Destruction Request

Instruction sheet

Dear C.D.S. Registrant, Please find enclosed with this letter, the New Jersey Drug Control Unit's (the "Unit") Controlled Dangerous Substance (C.D.S.) Destruction Request Form (DDC-51). Prior to destroying any C.D.S. drugs you must first receive explicit authorization from the Unit, including a designated authorization number. Please list all of the C.D.S. drugs you intend to destroy on the DDC-51 form (Section B) according to the instructions and examples specified thereon. The form may be reproduced if additional pages are needed. Upon completion of Section A and Section B, please submit a copy of the completed form to the Drug Control Unit via fax, e-mail or regular mail for review and issuance of an authorization number. Please retain the original DDC-51 form for your records. Next, the Unit will issue you an authorization number and a specific destruction date. Once authorization is granted by the Unit, you may destroy the C.D.S. drugs listed on your DDC-51 form. Upon the conclusion of the destruction of your C.D.S. drugs, please complete Section C, including "witness" and "destroyed by" signatures. Finally, submit to the Unit, via fax, e-mail or regular mail, a copy of the completed DDC-51 (all sections A, B & C) and retain the original form in your records.

Sincerely,

Drug Control Unit

9/19

New Jersey Office of the Attorney General

Division of Consumer Affairs Drug Control Unit P.O. Box 45045 Newark, New Jersey 07101 Telephone: 973-504-6351 Fax: 973-504-6326 Email: CDS@dca.

Authorization No:

CDS Office Use Only

Dosage Units:_ ___________________

Date destroyed:___________________

Controlled Dangerous Substances

Please type or print clearly and firmly.

Destruction Request

Please complete Section A and Section B and submit the form (via fax, e-mail or regular mail) to the Drug Control Unit for an authorization number. Do not destroy any C.D.S. until an authorization number is issued to you by the Drug Control Unit. Complete Section C after you receive an authorization number.

Section A

Registrant:____________________________________________________________________________________________________

Facility:______________________________________________________________________________________________________

Address:_____________________________________________________________________________________________________

Street address

City

State

ZIP code

C.D.S. number:____________________________________________ D.E.A. number:______________________________________

Contact person:____________________________________________ Telephone number:__________________________________

(include area code)

E-Mail address:_ ________________________________________________________________________

Reason for Destruction:

Outdated

Unwanted

Wasted

Best contact time between 8:30 a.m. - 4:00 p.m., Monday through Friday:_____________________________________

Section B

An exact count of C.D.S. drugs must be listed below. Instructions Column 1: List the name of the drug/medication and the dosage form (i.e. Tylenol with Codeine Tablets) Column 2: List the total number of tablets, capsules, suppositories, patches, ounces (ozs), milliliters (mls), grams (gms) in the

appropriate sub-column regardless of the containers from which they were removed. Column 3: List the controlled substances per dosage unit (i.e. mg/ml; mg/tab).

(1)

Name of Drug and Form

(2)

Total number of

Tabs, Caps, Supp., Patches

ml (Liquid)

g (powder and/

or topical)

(3)

C.D.S. Content Per Dosage

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

(1)

Name of Drug and Form

15. 16.

(2)

Total number of

Tabs, Caps, Supp., Patches

ml (Liquid)

g (powder and/

or topical)

(3)

C.D.S. Content Per Dosage

17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38.

39. 40.

Section C

When an authorization number is issued to you by the Drug Control Unit, please complete Section C, sign the form and submit (via fax, e-mail or regular mail) a copy of the completed Destruction Form to the Drug Control Unit.

I,_ _________________________________________ (print name), being of full age, certify and say under penalty of false statement, that I am the person described and identified in this certification; that the information given in this certification and all submitted materials contain no willful misrepresentations and that the information is true and complete. I understand that should an investigation at any time disclose otherwise, I and/or the licensee may face legal sanctions. I understand that in signing this certification of destruction, I am consenting to any reasonable inquiry that may be necessary to verify the information that I have provided on this form or may provide in conjunction with this certification.

Destroyed by: ________________________________________

Signature

Method of Destruction:

Witnessed by: ________________________________________

Print name

_____________________________________

Signature

Date destroyed:

DDC-51 Revised 9/19

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download