Controlled Substance Reconciliation Log Form
Use this Controlled Substance Reconciliation Log Form to accurately record and reconcile controlled substance inventory and activity.
Date of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location / Department
*
Responsible Staff Name
*
First Name
Last Name
Substance Name
*
Strength / Concentration
*
Quantity Received
*
Quantity Dispensed/Used
*
Current Balance
*
Reason for Adjustment
*
Please Select
Routine Dispense
Inventory Correction
Wastage/Disposal
Transfer
Other
Reviewer / Witness Name
*
First Name
Last Name
Submit Log Entry
Should be Empty: