Controlled Substance Inventory Form - New York State Department of Health
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement
CONTROLLED SUBSTANCE INVENTORY FORM
Name of Person Completing Form Signature Controlled Substance License #
Name of Controlled Substance Example: Lorazepam 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Title
Office Use Only
LOG NUMBER
Note: If the facility/program or individual is not subject to Article 33 controlled substance licensure, the applicable DEA registration number should be entered.
_____________________________
Strength/ Dosage Form
Quantity or Liquid Amount
Reason for Disposal/ Destruction
Source of Controlled Substance
Rx Number (Class 3A license
holders only)
0.5 mg Tablet
40
Discontinued
Smith Pharmacy
1234567
Click to Email Form
DOH-166 (7/10) Page 1 of 1
DOH-2340 Must Accompany This Form
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