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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 - Lors d'une perte durant le transport
  • 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/Pièce jointe
    • 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/Soumettre à
  Health Canada
  Office of Controlled Substances
  Compliance, Monitoring & Liaison Division
  A.L. 3502B
  Ottawa, ON K1A 1B9
  Tel.: (613) 954-1541
  Fax: (613) 957-0110