Request for Approval of Disposal/Destruction NEW YORK ...
Request for Approval of Disposal/Destruction
of Controlled Substances
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Narcotic Enforcement
SECTION I ¨C REQUEST INFORMATION
Office Use Only
3 Please use Adobe Acrobat to fill-in fields and save a copy on your computer.
3 Requests should be submitted to the applicable Bureau of Narcotic Enforcement office at
least 2 weeks prior to the proposed date of disposal/destruction.
3 Destruction must take place on a week day between 9 a.m. and 3 p.m. No weekends or holidays.
3 Email submissions to BNE are preferred to bnedestruction@health.
LOG
NUMBER
Approved
Partially Approved
Denied
Comment(s)
Licensee Name
*If using a P.O. Box,
a street address must
be included.
Street*
City
State
County
Telephone
Email Address
Zip
Fax
Controlled Substance License #
03A-
Note: If the facility/program or individual is not subject to Article 33
controlled substance licensure, the applicable DEA registration number
should be entered.
Date of Disposal/Destruction
Approved By
Start Time
_____ __ / ____ ___ / _______
AM
PM
Name
Method of Disposal/Destruction
Signature
Location of Disposal/Destruction (physical address) including room # or name
Date
PERSONNEL CONDUCTING DISPOSAL/DESTRUCTION
Name
Title
Professional
License #
Name
Title
Professional
License #
REQUESTOR AFFIRMATION
I hereby affirm that the controlled substances listed on the Controlled Substances Inventory Form (DOH-166) will be disposed of/destroyed as proposed in accordance with
applicable federal, state and local laws. No controlled substances will be disposed of/destroyed without written permission of the New York State Department of Health¡¯s Bureau
of Narcotic Enforcement.
Name
Title
Signature
Date
SECTION II -- STATEMENT OF DISPOSAL/DESTRUCTION (to be completed following disposal/destruction)
We, the undersigned, affirm that the controlled substances listed on the Controlled Substances Inventory Form (DOH-166) were disposed of/destroyed on
as approved in accordance with applicable federal, state and local laws.
Name
Name
Signature
Signature
DISPOSAL/DESTRUCTION MUST BE COMPLETED EXACTLY AS PROPOSED.
NO SUBSTITUTIONS OF DATE, TIME, LOCATION OR PERSONNEL WILL BE PERMITTED
WITHOUT PRIOR APPROVALBY THE BUREAU OF NARCOTIC ENFORCEMENT.
DISPOSAL/DESTRUCTION ACTIVITIES MAY BE OBSERVED BY THE BUREAU OF NARCOTIC ENFORCEMENT.
ALL CONTROLLED SUBSTANCES BEING DISPOSED OF OR DESTROYED ARE SUBJECT TO PHYSICAL INVENTORY.
DOH-2340 08/19
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