Controlled Substance Disposal Record
Document and verify the disposal of controlled substances for compliance and accountability.
Date and Time of Disposal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Substance Name
*
Substance Strength (e.g., 10mg/ml)
*
Form of Substance
*
Please Select
Tablet
Capsule
Liquid
Patch
Other
Quantity Disposed
*
Unit of Measurement
*
Please Select
mg
ml
tablets
capsules
patches
Other
Reason for Disposal
*
Please Select
Expired
Contaminated
Patient Refused
Partial Dose Remaining
Other
Method of Disposal
*
Please Select
Incineration
Flushing
Return to Manufacturer
Drug Take-Back Program
Other
Disposal Location
*
Name of Person Disposing Substance
*
First Name
Last Name
Name of Witness
*
First Name
Last Name
Additional Comments
Signature of Person Disposing Substance
*
Signature of Witness
*
Submit Record
Submit Record
Should be Empty: