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/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

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/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

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/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

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/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

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4KTbpVZMHxIccyp3WQIig93PbH4ZIcMZQjraLWQA45CQidFqyIoJNYNCvv53UKGURjmaGbLgC9Euz9huVdEzhb4LpBSzQjiQ2u42irJVorN8BFBbFF2q4T

Report of Loss or Theft of Controlled Substances

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MISSOURI BUREAU OF NARCOTICS AND DANGEROUS DRUGS

Missouri Regulation 19 CSR 30-1.034(2)(B) requires a registrant to notify the Bureau of the theft, diversion, or significant loss of any controlled substance upon discovery. This report must be submitted online within seven (7) days from the date of the loss.

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Initial Report Final Report

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M-D-Y

DPM

NURSING HOME KIT

DISTRIBUTOR

DVM

DDS

PHARMACY

IMPORTER/ EXPORTER

DMD

HOSPITAL

NARCOTIC TREATMENT PROGRAM

EMS

MANUFACTURER

TEACHING INSTITUTION

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Yes No

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Burglary

Robbery

Employee Theft/ Diversion

Lost in Transit

Forgery/ falsified records

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M-D-Y

Additional instruction:

1. Any drug that is lost with whereabouts unknown must be reported. Report any suspected theft or diversion regardless of the amount.
2. You are not required to report insignificant losses defined as fraudulent prescriptions submitted by customers; shortages in newly opened bottles from manufacturers, less than 3 doses lost within cabinets of automated dispensing machines, and broken tables, spills, leakage or amounts lost during compounding.
3. Section 195.045, RSMo 2000, states in material part that any person who reports or provides information to the Bureau pursuant to controlled substances laws, and does so in good faith to comply, shall not be subject to civil damages.
4. You may contact the Bureau at: P.O. Box 570, Jefferson City, MO 65102-0570, or call (573) 751-6321 or fax (573) 526-2569, or send email to: BNDD@health.mo.gov.

Please continue to next page to sign e-Consent and Submit the form.

***If more than 15 Drugs/ Trade Names needs to be entered, please submit another form (option available on the next page).***

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