Department of Health and Human Services

							                                                                      Department of Health and Human Services
                                                                                Licensing and Regulatory Services
                                                                                               41 Anthony Avenue
                                                                                          # 11 State House Station
                                                                                            Augusta, Maine 04333
                                                                     Tel: (207) 287-9300; Toll Free: 1-800-791-4080
                                                                          Fax: (207) 287-5807; TTY: 1-800-606-0215




                                      Facility Identification Form
                                        Medication Collection Event
                                         Week of April 30th , 2011



Facility Name: ________________________________________________________________________

Facility Address: ______________________________________________________________________
                     Street                        Town              Zip

Facility Contact Person: _________________________________________________________________

Facility Phone: ________________________________________________________________________

Witness name (please print):______________________________________________________________

Witness signature: ______________________________________________________________________

Law enforcement name (please print): ______________________________________________________

Law enforcement signature: ______________________________________________________________




Note: This form should accompany:

   1. A copy of your inventory list for non-controlled medications; and

   2. A copy of the list of Schedule II through V drugs from the Bound Book required under rules that have
      been surrendered to law enforcement for destruction. Please make sure that facility staff, the pharmacist
      and law enforcement signs or initials all inventory forms.




 For DEA use only: Weight of
 box(es):________________________________________

                                                                          DHHS-DLRS Drug Take Back Program Form 2011-01