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Narcotic Tracking
richard.mills2@gmr.net
2025-03-28T11:24:08-05:00
Narcotic Tracking Form
Step
1
of
7
14%
Type of Form
(Required)
Choose Type of Form
Daily Inventory Form
Narcotic Restocking Form
Usage/Waste Form
Is This a Crew Change?
(Required)
Select
Yes
No
Unit Number
(Required)
Unit Number
Unit 001
Unit 002
Unit 003
Unit 004
Unit 005
Unit 013
Unit 014
Unit 015
Unit 016
Unit 017
Unit 022
Unit 023
Unit 024
Unit 041
Unit 042
Unit 043
Unit 044
Unit 045
Unit 046
Unit 047
Unit 048
Unit 051
Unit 052
Unit 053
Unit 054
Unit 055
Unit 056
Unit 057
Unit 058
Unit 060
Unit 061
Unit 062
Unit 063
Unit 064
Unit 065
Unit 066
Unit 067
Unit 068
S100
S105
S106
S107
S109
S110
S120
S130
S140
S150
S160
HQ Narcotic Inventory
Spare HQ 01
Spare HQ 02
Surge 01
Surge 02
Surge 03
Surge 04
Surge 05
What type of narcotics do you have/being transfered/inventoried?
(Required)
CHECK ALL THAT APPLY
Fentanyl
Ketamine
Morphine
Versed
Run Number
(Required)
Transfering Unit Number
(Required)
Unit Number
Unit 001
Unit 002
Unit 003
Unit 004
Unit 005
Unit 013
Unit 014
Unit 015
Unit 016
Unit 017
Unit 022
Unit 023
Unit 024
Unit 041
Unit 042
Unit 043
Unit 044
Unit 045
Unit 046
Unit 047
Unit 048
Unit 051
Unit 052
Unit 053
Unit 054
Unit 055
Unit 056
Unit 057
Unit 058
Unit 060
Unit 061
Unit 062
Unit 063
Unit 064
Unit 065
Unit 066
Unit 067
Unit 068
S100
S105
S106
S107
S109
S110
S120
S130
S140
S150
S160
HQ Narcotic Inventory
Spare HQ 01
Spare HQ 02
Surge 01
Surge 02
Surge 03
Surge 04
Surge 05
Recieving Unit Number
(Required)
Unit Number
Unit 001
Unit 002
Unit 003
Unit 004
Unit 005
Unit 013
Unit 014
Unit 015
Unit 016
Unit 017
Unit 022
Unit 023
Unit 024
Unit 041
Unit 042
Unit 043
Unit 044
Unit 045
Unit 046
Unit 047
Unit 048
Unit 051
Unit 052
Unit 053
Unit 054
Unit 055
Unit 056
Unit 057
Unit 058
Unit 060
Unit 061
Unit 062
Unit 063
Unit 064
Unit 065
Unit 066
Unit 067
S100
S105
S106
S107
S109
S110
S120
S130
S140
S150
S160
HQ Narcotic Inventory
Spare HQ 01
Spare HQ 02
Surge 01
Surge 02
Surge 03
Surge 04
Surge 05
Narcotic Use/Waste
A new form must be completed for each TYPE of narcotic. (Example: If you use 2 vials of Drug A and 1 vial of Drug B, you must complete two forms. One for Drug A and One for Drug B.)
What type of narcotic was used/wasted?
(Required)
Choose Narcotic
Fentanyl
Ketamine
Morphine
Versed
Narcotic waste?
(Required)
Choose One
Yes
No
Amount of Narcotic Used?
(Required)
Amount of Narcotic Wasted?
(Required)
Number of Fentanyl
(Required)
Select Number
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
Fentanyl Control Number(s)
(Required)
F-0000 (Must Include Leading Letter and Dash) (Click + for each Fentanyl)
Transferring Control Number
Replacing Vial Control Number
Add
Remove
Fentanyl Control Number(s)
(Required)
F-0000 (Must Include Leading Letter and Dash) (Click + for each Fentanyl)
Add
Remove
Discrepency/ Comments:
Number of Ketamine
(Required)
Select Number
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
Ketamine Control Number(s)
(Required)
K-0000 (Must Include Leading Letter and Dash) (Click + to add for each Ketamine)
Transferring Control Number
Replacing Vial Control Number
Add
Remove
Ketamine Control Number(s)
(Required)
K-0000 (Must Include Leading Letter and Dash) (Click + to add for each Ketamine)
Add
Remove
Discrepency/ Comments:
Number of Morphine
(Required)
Select Number
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
Morphine Control Number(s)
(Required)
MS-0000 (Must Include Leading Letter and Dash) (Click + for each Morphine)
Transferring Control Number
Replacing Vial Control Number
Add
Remove
Morphine Control Number(s)
(Required)
MS-0000 (Must Include Leading Letter and Dash) (Click + for each Morphine)
Add
Remove
Discrepency/ Comments:
Number of Versed
(Required)
Select Number
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
Versed Control Number(s)
(Required)
V-0000 (Must Include Leading Letter and Dash) (Click + for each Versed)
Transferring Control Number
Replacing Vial Control Number
Add
Remove
Versed Control Number(s)
(Required)
V-0000 (Must Include Leading Letter and Dash) (Click + for each Versed)
Add
Remove
Discrepency/ Comments:
Verification of Waste
(Required)
I Verify
I verified that the listed controlled substance(s) listed above were wasted/disposed of according to policy.
Treating Medic Name
(Required)
First
Last
Treating Medic Signature
(Required)
Using Finger, sign below. If you do not see signature box please rotate phone sideways.
Witness of Waste Name
(Required)
First
Last
Witness of Waste Title
(Required)
Title of Witness
Physician
Registered Nurse
Other Healthcare Professional
Verification of Waste Witness
(Required)
I Witness
I witnessed the waste of the above-listed controlled substances.
Witness of Waste Signature
(Required)
Using Finger, sign below. If you do not see signature box please rotate phone sideways.
Medic Name
(Required)
First
Last
Medic Signature
(Required)
Using Finger, sign below. If you do not see signature box please rotate phone sideways.
Transfering Medic Name
(Required)
First
Last
Transfering Medic Signature
(Required)
Using Finger, sign below. If you do not see signature box please rotate phone sideways.
Recieving Medic Name
(Required)
First
Last
Recieving Medic Signature
(Required)
Using Finger, sign below. If you do not see signature box please rotate phone sideways.
Email
This field is for validation purposes and should be left unchanged.
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