Department of Environmental Health and Safety

DEA-Controlled Substances Witnessed Destruction Request

Please use this form to schedule a witnessed destruction for DEA-controlled substances. If you have any questions, please contact DEHS Hazardous Waste Coordinator at 502-852-2956.

Keep DEA controlled drugs secured until time of destruction.
Prepare USDOJ DEA Form 41 (search online). Information must exactly match DEA Registrant license. Print two copies.

Your Name

Your E-mail Address

Your Phone Number

DEA Registrant Name

Department

Lab Location (building and room #, room must have properly operating chemical fume hood)

Approx. liquid volume for destruction (mL)

Solid DEA material to destroy?

Yes
No

Requested dates/times