Controlled Substances Self Audit Checklist
GENERAL INFORMATIONLicensee/Registrant: FORMTEXT ?????Date: FORMTEXT ?????CONTROLLED SUBSTANCE PROCEDURESYesNoN/AResourcesRestricted access procedures are in place FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Secondary containers are labeled properly FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX AUTHORIZED AGENT RECORDSAuthorized Use OverviewCurrent list of authorized agents FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Authorized Agent LogAuthorized agent screening statements FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Authorized Agent QuestionnaireAuthorized agent delegation of responsibilities is documented FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Authorized Agent LogACQUISITION RECORDSRecords and Inventories OverviewAcquisition and ordering invoices FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Name, address and DEA # of supplier is on invoice FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Name, concentration/weight, dosage form, and quantity of substance received is on invoice FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Signature of person receiving shipment (needs to be an authorized user) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Date received FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Schedule I and II- copy 3 of DEA Form 222 must be completed and kept on file FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Schedule I and II records kept separate from all other records; III-V records kept separate from all other records or are readily retrievable FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DEA Form 222s are kept secure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ONGOING RECORDSRecords and Inventories OverviewGeneral inventory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX General Inventory SampleMultiple dose usage logs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Multiple Dose Usage Log SampleDiluted drug usage log FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Diluted Drug Solution Log SampleUse of drugs outside of registered location is documented FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FAQs: Registration and LicensingINVENTORY RECORDSRecords and Inventories OverviewInitial inventory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Initial Inventory Form SampleAnnual inventory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Annual Inventory Form SampleName, address and DEA # FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Date and time (beginning or end of day) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Signature of person taking inventory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Name of substance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Finished form of the substance (5-mg tablet; 5-mg/fluid oz.) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Number of units or volume of each finished form in each commercial container (e.g., 100-tablet bottle; 5-ml vial) For I and II make an exact count or measure of the contents—For III-V estimated count/measure unless container holds >1000 tablets then must be exact count FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Number of commercial containers of each finished form (e.g., 5 100-tablet bottles; 6 5-ml vials) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Schedule I and II inventories must be separated from schedule III-V inventories FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OTHER RECORDSTransfer records FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Disposal records (DEA Form 41) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????DEA Form 106 (theft/loss) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????All records kept for 2 years from the date of the record FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? ................
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