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Health Concerns

Loss and Theft Report Form

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Loss or Theft Report Form for Controlled Substances and Precursors

Office of Controlled Substances
File No.

  • Name
  • Date yyyy|mm|dd
  • Street
  • City
  • Province
  • Postal code
  • Telephone (      )
  • Pharmacy
  • Hospital
  • Practioner
  • Licensed Dealer
  • Registered Dealer
    • Registration Number:
  • Other (specify)
  • License Number:
  • Type of Loss
    • Break and entry
    • Pilferage
    • Loss unexplained
    • Armed Robbery
    • Grab theft
    • Loss in transit
    • Other (specify)
  • Has this been reported to the police?
    • Yes
    • No
    • Date yyyy|mm|dd
    • Name of police service
    • Incident number
    • Telephone Number
    • Name of investigating officer
  • Details of loss or theft discovery:
    • See Attachment
  • Description of physical security measures in place (Not applicable for licensed dealers of controlled substances)
    • See Attachment
  • Description of security measures put in place to prevent future loss or theft
    • See Attachment
  • For loss in transit
    • Investigation Report Received
    • Yes
    • No
  • List of controlled substances - precursors lost or stolen
    • Brand name and unit strength. If no brand name exists, the generic or other product name
    • Dosage form if applicable
    • Quantity
    • Brand name and unit strength. If no brand name exists, the generic or other product name
    • Dosage form if applicable
    • Quantity
  • *Please indicate if a separate page is attached
    • Attachment
      • Yes
      • No
  • Name and title of official individual reporting loss or theft (printed)
  • License or permit number for a practioner or pharmacist
  • Signature
  • Date yyyy|mm|dd
  • Submit to
    National Compliance Section
    Office of Controlled Substances
    Health Canada
    A.L. 0300B
    Ottawa ON K1A 0K9
    Tel.: 613-954-1541
    Fax: 613-957-0110