Controlled Drug Disposition/Administration Log Page 1 of ____ This form must be filled out by ANYONE using a controlled drug. Date In: Authorized User: Date Out: Drug & Class: Original Drug ID & Expiration Amount: Lot #: Date: Strength: Usage: Animal Use ________________ Chemical Research________________ Teaching/Instruction_______________ List Protocol # by project type: Purity: Original Container _____________ Combined Container______________ Slurry Bottle_______________ The Associate Registrant will fill in the Drug Transfer Log”, the top portion of this form and give the drug and this paper to the purchaser of the drug. “Controlled When/If the bottle is empty, expired, contaminated or is no longer needed, it is to be returned to the Associate Registrant with this log. (Associate Registrant Contact Info: Ph#___________, Bldg #_____, Rm#_____) DO NOT DISPOSE OF THE BOTTLE IN ANY OTHER WAY. Administered By: Species Animal ID Beginning Amount Running Date Administered Balance Administered Balance Print Name (If Using Animals) (If Using Animals) Initial If you need more space, begin a new Log” and staple together. “Disposition
Controlled Drug Disposition/Administration Log Page 1 of ____ This form must be filled out by ANYONE using a controlled drug. Authorized User: Date Out: Date In: Drug & Class: Original Amount: Drug ID & Lot #: Expiration Date: Strength: Usage: List Protocol # by project type: Animal Use ________________ Chemical Research________________ Teaching/Instruction_______________ Purity: Original Container _____________ Combined Container______________ Slurry Bottle_______________ The Associate Registrant will fill in the “Controlled Drug Transfer Log”, the top portion of this form and give the drug and this paper to the purchaser of the drug. When/If the bottle is empty, expired, contaminated or is no longer needed, it is to be returned to the Associate Registrant with this log. (Associate Registrant Contact Info: Ph#___________, Bldg #_____, Rm#_____) DO NOT DISPOSE OF THE BOTTLE IN ANY OTHER WAY. Date Administered Species (If Using Animals) Animal ID (If Using Animals) Beginning Balance Amount Administered Running Balance Administered By: Initial Print Name If you need more space, begin a new “Disposition Log” and staple together.
ControlledDrugDispositionLog2018.docx