Drug Diversion Request

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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

04/18/2025

Agency Name

Agency Number

Drugs Missing From

Signs of Physical Damage

Drugs in Locked Cabinet or Box

Type of Security System in Place

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

Was the Drug box returned to a Pharmacy?

List of the Drugs and Volumes Involved in the Diversion

Signature

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Drug Diversion

Hidden Items

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