Documentation of Drug Transfer Template SAMPLE
Purpose: The sample form provides law enforcement with a document that can be used to transfer drugs from the site of public collection to witnessed destruction at a state/federally-approved, thermal destruction facility managed as a Treatment, Storage, and Disposal Facility (TSDF) under 40 CFR, Parts 239 through 282. The Wisconsin Clean Sweep Program requires that all controlled substances and drugs with hazardous properties be disposed at such facilities. Detailed inventory sheets and other materials can accompany this form as drugs are transferred between parties.
Collection Site Generation: The __________________________________ (sponsoring agency) hereby certifies that on __________________, 2010, ______ sealed containers of controlled substances weighing _______ pounds, _______ ounces were generated at ____________________________________________ (address) as documented under case # ______. The attached inventory forms, if required, contain a complete record of all controlled substances placed in the above containers. Signatory, Title, and Date: ___________________________________________________________
Local Law Enforcement Acceptance: The _______________________________________ (agency) hereby confirms that on ____________________, 2010, received _______ sealed containers of controlled substances generated from the ________________________________________________ ( sponsoring agency) weighing _____ pounds, _____ ounces and will, if needed, safely secure them in an evidence vault until disposal arrangements have been completed. See case # _____ for details. Inventory forms, if required, of controlled substances provided by the Wisconsin Clean Sweep sponsor accompany this custodial transfer. Signatory, Title, and Date: ____________________________________________________________
Witness Burn Confirmation: ______________________________________ (TSDF company) hereby confirms that on _________________________, 2010, received _______ sealed containers of controlled substances generated at Wisconsin Clean Sweep collection sites weighing ______ pounds, ______ ounces from the __________________________________________ (law enforcement agency) and destructed them at ______________________ (facility) at _______ (time). Witnesses ________________________________________________________ (name & law enforcement agency) _________________________________________________________ (name & law enforcement agency) ______________________________________________________________ (name & title TSDF facility) _______________________________________________________________ (name & title TSDF facility)
NOTE: Please return a copy of this template to the sponsoring clean sweep agency once witness destruction has been completed.