NY Form 3848

Title 10 of New York State Rules and Regulations Part 80.136(j)(1) states that within 30 days of June 30th and December 31st of each year, an ALS agency shall submit a report for that six-month period to the department signed by the agent which report shall include the following:

(i) the name, address, and telephone number of the ALS agency;

(ii) the Bureau of Narcotic Enforcement license number;

(iii) the agent's name;

(iv) the total amount of controlled substances received from the dispensing hospital;

(v) the total amount of controlled substances dispensed to personnel;

(vi) the total amount of controlled substances returned from personnel;

(vii) the total amount of controlled substances lost for any reason;

(viii) the total amount of controlled substances on hand at the end of the period; and

(ix) an actual physical inventory count of all controlled substances on hand.

Starting a New Form 3848

Navigate to Forms > Form 3848

Add New Form & Select an Ending Date

Ensure Agency Information is Correct

Agency Name
Address
BNE Class 3C License #
NYS EMS Agency Code
DEA Registrant Name, Contact Info, & DEA Registration #
Controlled Substance Agent (CS Agent) Name & Contact Information

For guidance on changing agency information, see our article for NY Setup.

Conduct Physical Inventory of Products and Review S2 Values

Upon creating this form, the controlled substance names and amounts will be automatically calculated from the inventory events in Schedule2. Please be aware that this does NOT replace the need to conduct a physical count.

Following completion of a physical inventory, you should review the calculated values.

This form does not include reconciliations in its calculation and that you may have to adjust accordingly.
If this is your first time filling out this form in Schedule2, you will need to manually enter the last period's ending inventory amount (ml).
You will need to add manual entries for any inventory counts documented on paper that occurred prior to switching to Schedule2.

To make any necessary adjustments, select the "manual entry" tab for the desired controlled substance.

Both positive and negative values can be used to adjust the S2 values as needed.

*If there is any loss of controlled substances to be documented, a Form DOH 2094 must be filled out and attached with submission.

Signing the Form

The Controlled Substance Agent, Medical Director, and Agency CEO must all enter their titles and provide electronic signatures to finalize the form.

Once completed, the form is ready to print/submit. Click on "Print View" to print the form and/or save the form as a PDF.

Submitting the Form

The completed form must be submitted to both the Bureau of Narcotic Enforcement and the Bureau of EMS and Trauma:

Bureau of Narcotic Enforcement

E-mail documents to: bnelicensing@health.ny.gov

Or mail, only if necessary to:

Bureau of Narcotic Enforcement
Riverview Center
150 Broadway
Albany, NY 12204

Bureau of EMS and Trauma

NYS DOH Bureau of EMS & Trauma
875 Central Avenue
Albany, NY 12206