Controlled Substances Compliance Form
Please complete this form to document compliance in the handling, storage, and disposal of controlled substances.
Responsible Party Name
*
First Name
Last Name
Responsible Party Email Address
*
example@example.com
Responsible Party Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Facility/Department Name
*
Date of Compliance Check
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Controlled Substance Details
*
Is the inventory accurate and reconciled with records?
*
Yes
No
Are all controlled substances stored securely (locked, restricted access)?
*
Yes
No
Describe any discrepancies, incidents, or missing substances (if any)
Controlled Substance Disposal Record (if applicable)
Signature of Responsible Party
*
Submit Compliance Report
Submit Compliance Report
Should be Empty: