Drug Diversion Request

Virginia EMS Regulations 12VAC5-31-520.D requires an EMS Agency to notify the Office of Emergency Medical Services in writing of any diversion of (i.e., loss or theft) or tampering with any controlled substances, drug delivery devices, or other regulated medical devices from an agency, facility or vehicle. Notification shall be made within 15 days of the discovery of the occurrence.

Date of Report

04/24/2024

First Name

Last Name

Address Line 1

Address Line 2

City

State

Primary Phone #

Alternate Phone #

Agency Name

Agency Number

Drugs Missing From

Drugs Missing Description

Signs of Physical Damage

Describe

Drugs in Locked Cabinet or Box

Other

Type of Security System in Place

Other

Time Discovered

Diversion Occurred Address Line 1

Diversion Occurred Address Line 2

Diversion Occurred City

Diversion Occurred State

Discovered Organization Name

Discovered Person First Name

Discovered Person Middle Name

Discovered Person Last Name

Discovered Person Address Line 1

Discovered Person Address Line 2

Discovered Person City

Discovered Person State

Primary Phone #

Alternate Phone #

Has Local Law Enforcement Been Contacted

Law Enforcement Agency Name

Investigating Officer First Name

Investigating Officer MI

Investigating Officer Last Name

Investigating Officer Phone#

Was the Drug box returned to a Pharmacy?

Name of the Pharmacy Drug Box was returned to

List of the Drugs and Volumes Involved in the Diversion

Signature

Drug Diversion Header context

Drug Diversion