Controlled Drug Incident Report Form
Report and document incidents involving controlled drugs for compliance and investigation.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Type of Controlled Drug Involved
*
Please Select
Morphine
Fentanyl
Oxycodone
Methadone
Other (please specify)
Quantity Involved (e.g., number of vials, tablets)
*
Describe the Incident in Detail
*
Persons Involved (names and roles)
*
Immediate Actions Taken
*
Was the incident witnessed?
*
Yes
No
Witness Name(s) and Contact Information (if applicable)
Reporting Staff Name and Position
*
Follow-up Actions or Investigation Notes
Signature of Reporting Staff
*
Submit Report
Submit Report
Should be Empty: