The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

8RKeMZVs8sBtCukfhjMhFGIyjWBqTEzIFfEpk3PCZ3PDGSfuDdP7V43XetkcfSMLCoLpvRH

Report of Loss or Theft of Controlled Substances

Returning?

A A A

MISSOURI BUREAU OF NARCOTICS AND DANGEROUS DRUGS

Missouri Regulation 19 CSR 30-1.034(2)(B) requires a registrant to notify the Bureau of the theft, diversion, or significant loss of any controlled substance upon discovery. This report must be submitted online within seven (7) days from the date of the loss.

* must provide value are required fields.

Initial or Final Report

* must provide value

Initial Report Final Report

reset

Missouri BNDD Registration Number

* must provide value

Federal DEA Registration Number

Registrant Email

* must provide value

Name of Registrant

* must provide value

Street Address

* must provide value

City in Missouri

* must provide value

State

Zip Code

* must provide value

County in which located

* must provide value

Area Code and Phone Number

* must provide value

Date(s) of Theft or Discovery

* must provide value

M-D-Y

Date Reported to DEA

M-D-Y

Principal Business of Reporting Registrant

* must provide value

DPM

NURSING HOME KIT

DISTRIBUTOR

DVM

DDS

PHARMACY

IMPORTER/ EXPORTER

DMD

HOSPITAL

NARCOTIC TREATMENT PROGRAM

EMS

MANUFACTURER

TEACHING INSTITUTION

reset

Was theft reported to Police?

* must provide value

Yes No

reset

Name of Police Agency

Type of Theft or Loss

* must provide value

Burglary

Robbery

Employee Theft/ Diversion

Lost in Transit

Forgery/ falsified records

reset

Name of Common Carrier

* must provide value

Name of Consignee

* must provide value

Origin of Delivery (Street Address)

* must provide value

Origin of Delivery (Zip Code)

* must provide value

Origin of Delivery (State)

* must provide value

Name(s) of Person(s) who committed theft or diversion

Summary

* must provide value

Expand

Trade or Brand Name

Generic Name

Dosage Strength & Form

Quantity

Add More drug name, strength, dosage and quantity (up to 15, please select Yes to the right to add more/ or below on mobile devices)?

If more than 15 drugs, please submit another form on the next page.

Yes No

reset

Trade or Brand Name 2

Generic Name 2

Dosage Strength & Form 2

Quantity 2

Trade or Brand Name 3

Generic Name 3

Dosage Strength & Form 3

Quantity 3

Trade or Brand Name 4

Generic Name 4

Dosage Strength & Form 4

Quantity 4

Trade or Brand Name 5

Generic Name 5

Dosage Strength & Form 5

Quantity 5

Trade or Brand Name 6

Generic Name 6

Dosage Strength & Form 6

Quantity 6

Trade or Brand Name 7

Generic Name 7

Dosage Strength & Form 7

Quantity 7

Trade or Brand Name 8

Generic Name 8

Dosage Strength & Form 8

Quantity 8

Trade or Brand Name 9

Generic Name 9

Dosage Strength & Form 9

Quantity 9

Trade or Brand Name 10

Generic Name 10

Dosage Strength & Form 10

Quantity 10

Trade or Brand Name 11

Generic Name 11

Dosage Strength & Form 11

Quantity 11

Trade or Brand Name 12

Generic Name 12

Dosage Strength & Form 12

Quantity 12

Trade or Brand Name 13

Generic Name 13

Quantity 13

Trade or Brand Name 14

Generic Name 14

Dosage Strength & Form 14

Quantity 14

Trade or Brand Name 15

Generic Name 15

Dosage Strength & Form 15

Quantity 15

Print Name

* must provide value

Upload Attachments (such as supporting documents)

Upload file

Title

* must provide value

Today's Date

* must provide value

M-D-Y

Additional instruction:

1.Any drug that is lost with whereabouts unknown must be reported. Report any suspected theft or diversion regardless of the amount.
2.You are not required to report insignificant losses defined as fraudulent prescriptions submitted by customers; shortages in newly opened bottles from manufacturers, less than 3 doses lost within cabinets of automated dispensing machines, and broken tables, spills, leakage or amounts lost during compounding.
3.Section 195.045, RSMo 2000, states in material part that any person who reports or provides information to the Bureau pursuant to controlled substances laws, and does so in good faith to comply, shall not be subject to civil damages.
4.You may contact the Bureau at: P.O. Box 570, Jefferson City, MO 65102-0570, or call (573) 751-6321 or fax (573) 526-2569, or send email to: BNDD@health.mo.gov.

Please continue to next page to sign e-Consent and Submit the form.

***If more than 15 Drugs/ Trade Names needs to be entered, please submit another form (option available on the next page).***

Mark field as:

[Clear value]

No information (NI)

Invalid (INV)

Unknown (UNK)

Not asked (NASK)

Asked but unknown (ASKU)

Temporarily unavailable (NAV)

Masked (MSK)

Not applicable (NA)

Not available (NAVU)

Not present (NP)

Sufficient quantity (QS)

Trace (TRC)

Unencoded (UNC)

Derived (DER)

Positive infinity (PINF)

Negative infinity (NINF)

Other (OTH)

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.