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Environmental Health & Safety

 

Controlled Substance Request for Registration Information

Marked fields are required.

Researcher Information

Principal Investigator Name:
Department:

Office:

Building:
Room:
Campus Phone:
Email:
Home Address:
City:
State: Zip Code:
Driver's License Number:
Driver's License Issuing State: Date of Birth:

Have you ever been convicted of a crime in connection with controlled substances under state or federal law?
NoYes

Have you ever surrendered or had a federal controlled substance registration revoked, suspended, restricted or denied?
NoYes

Have you ever had a state professional license or controlled substance registration revoked, suspended, denied, restricted, or placed on probation?
NoYes

Facility Information

Drug Storage Location:

Building:
Room:
Will the Use Location be different than the Storage Location? NoYes

Staff and Personnel Information

List all individuals who will have access to the controlled substance. Be advised, you will need to provide a completed Employee Questionnaire for each individual.

NamePosition

Research Project Information

Name of Research Project or Protocol: Grant Number or Funding Source (if applicable):
Please provide a description of the purpose of the research and the purpose of the controlled substance(s) in the research in one paragraph:

Controlled Substances

A complete list of DEA Controlled Substances can be found here.

Drug:
Dose or Dose Range to be administered to animals:
Method or Route of Delivery:
Estimated Amount of Drug Purchased (stock amount in grams, milliliters, etc.):
Stock Drug Concentration:
Purchasing Frequency (number of orders placed per year):
Briefly Describe Purpose of drug in Research:

Suppliers

The following are commonly used suppliers and EH&S suggests that all are included so that you can purchase from them. Any additional vendors should be listed after. If you know for certain that you will not be purchasing from the suggested vendors, please uncheck them.

Henry Schein
Butler
MWI Veterinary Supply
Sigma Aldrich

Additional Supplier(s)/Vendor(s):

Supplier/VendorAddressPhone Number

Security and Storage

Do you have a safe or secure storage cabinet that will be used to store your controlled substances? EH&S can advise you on the type of safe to purchase.
NoYes

Recordkeeping

Indicate what type of recordkeeping forms you are planning to use:

EHS Controlled Substance Use Log
Other Use Log

Animal Usage

List any research animal(s) that will be exposed to controlled substances.

Animal SpeciesApproximate Number per Year

Curricula Vitae

Please send a copy of your current Curricula Vitae to EHS via email as soon as possible.

Comments:

Drugs will not be sold, traded, or transferred to anyone not directly involved in the specific research project for which the drug was obtained. Security and recordkeeping (of drug acquisition and disposition) will be maintained. These records will be audited by EH&S in accordance with the requirements of the EH&S Rx Drug Distributor - Health Care Entity license on which drugs are purchased.)

This information to be kept on file as required by Florida Administrative Code 64F-12.023(2).

The submitted information will be used to complete a DEA license application. By completing and submitting this form, I agree to permit EH&S personnel to enter the information into the DEA database for my license application.