Initial or Final Report
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Initial Report Final Report
Initial or Final Report (please select one )
Missouri BNDD Registration Number
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Missouri BNDD Registration Number
Federal DEA Registration Number
Federal DEA Registration Number
Registrant Email
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Registrant Email
Name of Registrant
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Name of Registrant
Street Address
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Street Address
City in Missouri
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City
State
State
Zip Code
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Zip Code
County in which located
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County in which located
Area Code and Phone Number
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Area Code and Phone Number
Date(s) of Theft or Discovery
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Today M-D-Y Date(s) of Theft or Discovery
Date Reported to DEA
Today M-D-Y Date Reported to DEA
Principal Business of Reporting Registrant
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MD
DO
DPM
NURSING HOME KIT
DISTRIBUTOR
OD
DVM
DDS
PHARMACY
IMPORTER/ EXPORTER
DMD
HOSPITAL
NARCOTIC TREATMENT PROGRAM
EMS
MANUFACTURER
TEACHING INSTITUTION
Principal Business of Reporting Registrant
Was theft reported to Police?
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Yes No
Was theft reported to Police?
Other
Name of Police Agency
If Theft reported to Police, please type Name of Police Agency
Type of Theft or Loss
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Burglary
Robbery
Employee Theft/ Diversion
Lost in Transit
Forgery/ falsified records
Type of Theft or Loss
Name of Common Carrier
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Name of Common Carrier (for ex: Fedex, UPS, USPS, etc.)
Name of Consignee
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Name of Consignee (for ex: Pharmacy Name, etc.)
Origin of Delivery (Street Address)
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Origin of Delivery (Address of the Distributor)
Origin of Delivery (Zip Code)
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Origin of Delivery (Zip Code)
Origin of Delivery (State)
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Origin of Delivery (State)
Name(s) of Person(s) who committed theft or diversion
Name(s) of Person(s) who committed theft or diversion
Other
Trade or Brand Name
Trade or Brand Name
Generic Name
Generic Name
Dosage Strength & Form
Dosage Strength & Form
Quantity
Quantity
Add More drug name, strength, dosage and quantity (up to 15, please select Yes to the right to add more/ or below on mobile devices)?
If more than 15 drugs, please submit another form on the next page.
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Add More drug name, strength, dosage and quantity?
Trade or Brand Name 2
Trade or Brand Name 2
Generic Name 2
Generic Name 2
Dosage Strength & Form 2
Dosage Strength & Form 2
Quantity 2
Quantity 2
Trade or Brand Name 3
Trade or Brand Name 3
Generic Name 3
Generic Name 3
Dosage Strength & Form 3
Dosage Strength & Form 3
Quantity 3
Quantity 3
Trade or Brand Name 4
Trade or Brand Name 4
Generic Name 4
Generic Name 4
Dosage Strength & Form 4
Dosage Strength & Form 4
Quantity 4
Quantity 4
Trade or Brand Name 5
Trade or Brand Name 5
Generic Name 5
Generic Name 5
Dosage Strength & Form 5
Dosage Strength & Form 5
Quantity 5
Quantity 5
Trade or Brand Name 6
Trade or Brand Name 6
Generic Name 6
Generic Name 6
Dosage Strength & Form 6
Dosage Strength & Form 6
Quantity 6
Quantity 6
Trade or Brand Name 7
Trade or Brand Name 7
Generic Name 7
Generic Name 7
Dosage Strength & Form 7
Dosage Strength & Form 7
Quantity 7
Quantity 7
Trade or Brand Name 8
Trade or Brand Name 8
Generic Name 8
Generic Name 8
Dosage Strength & Form 8
Dosage Strength & Form 8
Quantity 8
Quantity 8
Trade or Brand Name 9
Trade or Brand Name 9
Generic Name 9
Generic Name 9
Dosage Strength & Form 9
Dosage Strength & Form 9
Quantity 9
Quantity 9
Trade or Brand Name 10
Trade or Brand Name 10
Generic Name 10
Generic Name 10
Dosage Strength & Form 10
Dosage Strength & Form 10
Quantity 10
Quantity 10
Trade or Brand Name 11
Trade or Brand Name 11
Generic Name 11
Generic Name 11
Dosage Strength & Form 11
Dosage Strength & Form 11
Quantity 11
Quantity 11
Trade or Brand Name 12
This field is autocompleted based on user typing
Generic Name 12
Generic Name 12
Dosage Strength & Form 12
Dosage Strength & Form 12
Quantity 12
Quantity 12
Trade or Brand Name 13
This field is autocompleted based on user typing
Generic Name 13
Generic Name 13
Quantity 13
Quantity 13
Trade or Brand Name 14
Trade or Brand Name 14
Generic Name 14
Generic Name 14
Dosage Strength & Form 14
Dosage Strength & Form 14
Quantity 14
Quantity 14
Trade or Brand Name 15
Trade or Brand Name 15
Generic Name 15
Generic Name 15
Dosage Strength & Form 15
Dosage Strength & Form 15
Quantity 15
Quantity 15
Print Name
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Print Name
Upload Attachments (such as supporting documents)
Upload Attachments
Title
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Title
Today's Date
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Today M-D-Y Today's Date
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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