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Key
Components
of the Policy:
Registration
- All registrations
must be coordinated through the DEHS. [Application form: http://www.dehs.umn.edu/ihsd/controlledsubs/forms.html]
- Registrations for research and
teaching activities must be maintained separately from clinical
registrations.
- Each
Unit must designate a Unit Registrant to hold the DEA registration as
well as Minnesota Board of Pharmacy (MNBP) registrations. A DEA
registration is required to purchase controlled substances. Under the
revised policy, only a Unit Registrant or an "exempted" Location
Registrant is allowed to hold a DEA registration for research or
teaching purposes.
- Each Location (non-contiguous)
must designate a Location Registrant to hold the Minnesota Board of
Pharmacy (MNBP) registration. Location Registrants are responsible for
all controlled substances used and records maintained at their Location.
- Each
Location Registrant must designate Authorized User(s) who are eligible
to receive and/or use controlled substances under the Location
Registrant's MNBP registration. Authorized Users must be listed on the
Location Registrant's University Registration record, which is
maintained by DEHS.
- All controlled substance use must be
described in an approved Animal Usage Form, Human Subjects Application
Form, grant or other research protocol, as appropriate for the
situation.
Purchase
- Controlled
substances must be purchased through a Unit Registrant. The Unit
registrant may purchase from commercial suppliers, Boynton Health
Service Pharmacy or the College of Veterinary Medicine Pharmacy.
- Unit
Registrants are responsible for determining that the person requesting
the purchase has a current MNBP registration and a valid use for the
substance. They are also responsible for the acquisition and
disposition records of the drug purchases they authorize.
- Schedule
I and II drugs must be purchased using a DEA Form 222. Vendors who sell
Schedule III-V drugs usually require that a copy of the Unit
registrant's DEA registration be provided annually.
- If
personnel other than a registrant are to receive controlled substances,
they must be listed on the University registration record as Authorized
Users.
Inventory
and record keeping
- Records
must be maintained on-site. Financial and shipping records may be
maintained centrally if there is prior notification to the DEA of this
intent.
- Separate records must be maintained
for
each Schedule I and II controlled substance used. Schedule III-V
controlled substances records may be maintained together as long as the
use of each individual drug can be identified.
- Records
(continuous inventory) must include information on the
purchase/acquisition; quantity used; annual inventory and
reconciliation; and disposition/disposal for all controlled substances.
The date of each activity and the initials of the Authorized User
documenting the information must also be recorded. (The inventory form
"Research Controlled Substance Disposition Record" is available at: http://www.dehs.umn.edu/ihsd/controlledsubs/forms.html
- Location Registrants should keep a log
of Authorized Users with their names, signatures and initials.
- Records
must be maintained for a minimum of 3 years. (The FDA or study sponsor
may require records to be maintained for a longer period. Please
contact your study sponsor, Meg Becker (626-1462) or Lisa Frankamp
(624-2431) at the ORA with questions about records retention.)
- A
record of individual administration must be maintained for all Schedule
I and II controlled substances. The information that must be documented
includes: name and dose of controlled substance; date of
administration; and signature/initials of the Authorized User
administering the drug. The initials/number of each subject receiving
the drug must be documented for research involving human and animal
subjects.
Security
- Controlled
substances must be stored in a securely locked cabinet or safe, as
specified in the regulations, and separately from other materials.
- Access to controlled substances should
be limited to the minimum number of people necessary.
- Ancillary security measures such as
alarms or a locked room are also needed.
- Information on approved safes and "how
to order" may be obtained from Greg Casura (626-5338).
- DEHS will review your security
measures at no charge. Call Greg Casura (626-5338) for more information.
Reporting
- Discrepancies in drug
inventories must be reported to DEHS and University Police immediately.
- An annual self-audit report must be
provided to DEHS.
(For more information, contact us,
or refer to Training Facts)
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