Loss or Theft Report Form

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Loss or Theft Report Form for Controlled Substances and Precursors (Appendix A)

Office of Controlled Substances/Office of Medical Cannabis
File No.

  • Name of Establishment
  • Type of Report
    • New
    • Amendment
    • Recovery
  • Date of Discovery
  • Street
  • City
  • Province
  • Postal Code
  • Telephone
  • Type of Establishment
    • Click to see options
    • CDSA Section 56 Exemptee
    • Hospital
    • Licensed Dealer
    • Licensed Holder
    • Licensed Producer
    • Licensed Researcher
    • Pharmacy
    • Practioner
    • Registered Dealer
    • Registered Person
    • Other (Specify)
  • Click to see options
    • Authorization number
    • Licence number
    • Pharmacy Licence number
    • Practitioner Licence number
    • Registration number
    • Other
  • Type of Loss or Theft
    • Click to see options
    • Armed Robbery
    • Break and Entry
    • Grab Left
    • Loss in Transit
    • Loss Unexplained(1)
    • Loss Unexplained(2)
    • Loss Unexplained(3)
    • Pilferage
    • Unusual Waste
    • Other
  • If other Specify
  • Has this been reported to the police?
    • Yes
    • No
    • Date
  • Name of the Police Service
  • Incident number
  • Telephone number
  • Name of Investigating officer
  • E-mail of Investigating officer
  • For loss in transit/Name of the transport company
  • Investigation Report
  • Received
    • Yes
    • No
  • Report number
  • List of controlled substances and/or precursors lost or stolen
    • Trade name and unit strength. If no trade name exists, the generic or other product name of the manufacturer
    • Dosage form if applicable
      • Click to see options
      • ampule
      • capsule
      • drops
      • dry material
      • gel cap
      • injectable
      • liquid
      • patch
      • plant
      • powder
      • pump
      • sachet
      • sample
      • seed
      • suppository
      • tablet
      • topical cream
      • vaporizer
      • vial
    • Unit of measurement
      • gal (gallons)
      • g (grams)
      • kg (kilograms)
      • mg (milligrams)
      • ug (micrograms)
      • ml (millilitres)
      • L (litres)
      • lb (pounds)
      • oz (onces)
      • F oz (fluid onces)
      • tons
    • Quantity
    • Din/NPN or Lot #
  • Please indicate if a separate page is attached
    • Yes
    • No
  • Please attach the following as separate pages
    • Details of loss or theft discovery (including occurrence date if known)
    • Description of physical security measures in place (for Licensed Dealers, if different than on file with the Authorization Division at the Office of Controlled Substances)
    • Authorization Division at the Office of Controlled Substances) –
    • Description of security measures put in place to prevent future loss or theft
    • Copy or summary of the report submitted to the Police
  • Name and title of official individual reporting loss or theft (printed)
  • Licence number
  • Signature
  • Date
  • E-mail address
  • Submit to
    • Health Canada Office of Controlled Substances
      161 Goldenrod Driveway A.L. 0300B
      Ottawa ON K1A 0K9
      Tel.: 613-952-2177
      Toll Free: 1-866-569-2560
      Fax: 613-957-0110
      Email: OCS_Reporting_Rapporter_BSC@hc-sc.gc.ca

      Health Canada Office of Medical Cannabis A. L. 0300B
      161 Goldenrod Driveway A.L. 0300B
      Ottawa ON K1A 0K9
      Toll Free: 1-866-337-7705
      Fax: 613-941-6840
      Email: CMC@hc-sc.gc.ca
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