Iowa Board of Pharmacy

susan.wennekamp@iowa.gov

6200 Park Ave., Ste. 100 Des Moines, IA 50321

515-242-3272

Report of Theft or Loss of Precursor Substances

Iowa Law requires submission of a detailed report of any theft or loss of Precursor Substance to the Iowa Board of Pharmacy. Please fill out this form in its entirety. A copy will be sent to the designated email adresss after submission.

Name of Vendor/Recipient

Phone Number

Iowa Permit No. (if applicable)

Reporting Vendor is:

Recipient Vendor

Provider Vendor

List of Precursor Substances Lost/Stolen

Include Name of Substance, Form of Substance (e.g. powder, liquid), and Quantity

Click "Add item" to add another missing substance

Remove Field

Add item

Signature of Authorized Individual

First Name

Last Name

Choose how to sign

Draw Type

I hereby swear under penalty of perjury that the information provided herein is true and correct to the best of my knowledge and belief.

Title of Authorized Individual above

Information provided on this report may be disclosed pursuant to 657 Iowa Administrative Code Chapter 14.