Complete this form before initially obtaining, using, or storing controlled substances in research. Submit the completed form to Environmental Health and Safety before beginning work with controlled substances.

Instructions

Complete this form before initially obtaining, using, or storing controlled substances in research. Submit the completed form to Environmental Health and Safety before beginning work with controlled substances.

Section 1. Principal Investigator / Registrant Information

Name(Required)

First Last

Title / Position:(Required)

Department(Required)

Building / Room(Required)

Email(Required)

Phone(Required)

DEA Registration Number

NCDHHS Registration Number

Section 2. Controlled Substance Use Information

Will controlled substances be used in this research?(Required)

Yes

No

Purpose of Use(Required)

Anesthesia

Analgesia

Tranquilization

Sedation

Hypnosis

Other

Brief Description of Research Activity(Required)

Species / Model / Project Description(Required)

Section 3. Controlled Substances Requested or Used

Controlled Substance 1

Substance Name

Schedule

Estimated Annual Quantity

Form/Strength

Estimated Starting Date

Estimated Ending Date

Controlled Substance 2

Schedule

Substance Name

Estimated Annual Quantity

Form/Strength

Estimated Starting Date

Estimated Ending Date

Additional Controlled Substances

Add additional controlled substances if applicable

Controlled Substances

Section 4. Storage and Security

Storage method(Required)

Locked controlled substance container inside locked cabinet

Locked cabinet in locked room

Approved safe / steel cabinet / vault

Refrigerator with lock box, if applicable

Other

Will the storage location be accessible only to authorized personnel?(Required)

Yes

No

Will two locks be used for controlled substances, as required?(Required)

Yes

No

Describe access controls / key control procedures(Required)

Section 5. Authorized Users

Individuals who may have access to or handle controlled substances under this registration(Required)

Include full name, title, department, access level, and confirm training complete.

Are Employee Security Questionnaires maintained for authorized users, as required?(Required)

Yes

No

Section 6. Recordkeeping and Inventory

Will controlled substance use, receipt, and disposal be documented in a written record?(Required)

Yes

No

Will inventories be performed at least every two years and reviewed quarterly as a best practice?(Required)

Yes

No

Will Schedule I substances, if any, be maintained in a separate record and bound book?(Required)

Yes

No

Not Applicable

Describe the recordkeeping system to be used(Required)

Section 7. Ordering and Disposal

Ordering method expected to be used(Required)

DEA Form 222 / current DEA-authorized ordering method

University Procurement Services

NIH source

Other

Will disposal of controlled substances be documented and coordinated in accordance with institutional and regulatory requirements?(Required)

Yes

No

Will Environmental Health and Safety be contacted before disposal if there are questions regarding the proper method?(Required)

Yes

No

Section 8. Compliance Attestation

Compliance Attestation.

I agree to the following:

I understand that I am responsible for compliance with all applicable federal, state, and institutional requirements governing the receipt, storage, use, recordkeeping, inventory, and disposal of controlled substances. I understand that I must notify Environmental Health and Safety before initiating controlled substance use and when controlled substances are no longer being used under this registration.

Name

First Last

Date

MM slash DD slash YYYY

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Environmental Health & Safety

The Office of Environmental Health & Safety is committed to the protection of our natural environment through proper management and control of the resources used by the university for academic, research, and support operations.

336.758.EHAS (3427)

A Private Liberal Arts University in Winston-Salem, NC / Founded 1834 / Motto: Pro Humanitate