DA Form 3949 Controlled Substances Record

DA Form 3949 - also known as the "Controlled Substances Record" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 3949 - was last revised on September 1, 2009. Download an up-to-date fillable PDF version of the DA 3949 down below or look it up on the Army Publishing Directorate website.

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DATE INITIATED
This form is to be used in
WARD/CLINIC
(YYYYMMDD)
CONTROLLED SUBSTANCES RECORD
conjunction with DA Form 3949-1
For use of this form, see AR 40-3; the proponent agency is OTSG.
MONTH/YEAR
ITEM
FORM INITIATED
BALANCE FORWARDED
(Generic Nomenclature; may add trade name for additional clarity)
ACCOUNTABLE UNIT
(Sign and Print Name)
(From the previous sheet)
BALANCE
DAY
HOUR
PATIENT NAME
ORDERED BY
ADMINISTERED BY
WITNESS TO ANY WASTE
EXPENDITURES RECEIPTS
ACTUAL DOSE
AMOUNT OF
(Accountable units
(Last Name, First Name)
(Dr.'s Last Name)
(Sign on top line; Print
(Sign on top line; Print
(Amount from
(Accountable
ADMINISTERED
MEDICATION
name on bottom line)
name on bottom line)
used)
pharmacy)
Units Remaining)
TO PATIENT
WASTED
APD LC v1.00
DA FORM 3949, SEP 2009
PREVIOUS EDITIONS ARE OBSOLETE.
DATE INITIATED
This form is to be used in
WARD/CLINIC
(YYYYMMDD)
CONTROLLED SUBSTANCES RECORD
conjunction with DA Form 3949-1
For use of this form, see AR 40-3; the proponent agency is OTSG.
MONTH/YEAR
ITEM
FORM INITIATED
BALANCE FORWARDED
(Generic Nomenclature; may add trade name for additional clarity)
ACCOUNTABLE UNIT
(Sign and Print Name)
(From the previous sheet)
BALANCE
DAY
HOUR
PATIENT NAME
ORDERED BY
ADMINISTERED BY
WITNESS TO ANY WASTE
EXPENDITURES RECEIPTS
ACTUAL DOSE
AMOUNT OF
(Accountable units
(Last Name, First Name)
(Dr.'s Last Name)
(Sign on top line; Print
(Sign on top line; Print
(Amount from
(Accountable
ADMINISTERED
MEDICATION
name on bottom line)
name on bottom line)
used)
pharmacy)
Units Remaining)
TO PATIENT
WASTED
APD LC v1.00
DA FORM 3949, SEP 2009
PREVIOUS EDITIONS ARE OBSOLETE.

Download DA Form 3949 Controlled Substances Record

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