CONTROLLED DRUG WASTAGE — WITNESSED DESTRUCTION
Hospital: ________________________ | Dept Anesthesia	Form Code: F-23 | Version: ___ | Effective: ___ | PAGE 1 of 1

SECTION 1 — PATIENT / CASE
Date: _______________________ Time: _______________________	Location: ☐ OR    ☐ PACU    ☐ NORA    ☐ Block Area
Patient Name (optional per policy): ________________________________________________	MRN / Case ID: ________________________________________________

SECTION 2 — DRUG DETAILS
Drug name: ________________________________________	Strength / Concentration: ________________________________	Form: ☐ Ampoule    ☐ Vial    ☐ Syringe
Amount prepared: ________________________________________	Amount administered: ________________________________	Amount wasted: ________________________________
Reason for wastage:    ☐ Dose change    ☐ Case cancelled    ☐ Partial dose    ☐ Other: ___________________________

SECTION 3 — WASTAGE METHOD

Method used: ☐ Approved controlled-drug destruction container ☐ Pharmacy-return system ☐ Other approved method: _______________________________________________________________ Wastage performed immediately after administration:    ☐ Yes    ☐ No (explain below) Explanation: ____________________________________________________________________________________

SECTION 4 — WITNESS SIGNATURES
Administrator (Name/ID): ________________________________________	Signature: ________________________________________	Time: ________________
Witness (Name/ID): ________________________________________	Signature: ________________________________________	Time: ________________
Optional notes: ____________________________________________________________________________________________________________________