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��� RxPATROL® (Rx Pattern Analysis Tracking Robberies & Other Losses)
RxPATROL® (Rx Pattern Analysis Tracking Robberies and Other Losses) RxPATROL®
Rx Pattern Analysis Tracking Robberies & Other Losses
Note: If form is to be printed, printer margins must be set to 0.5."

One Stamford Forum
Stamford, CT 06901
Fax Number (203) 588 6236
Section One
Business Name:          Store Number: 
*If Business Name is not listed select "OTHER", then manually enter the name in the Store Number field
Incident Address:

Street

City 		 State
Zip

Country
Phone (Optional)
Date of Incident:     Day of Week of Incident:      Time of Incident: 
Vehicle Information:
 
Make		  
Model		  
Color
# Doors
 
Style		  
License #		 State
Law Enforcement Report #:      Police Department: 
Reporting Officer (Optional):  Phone (Optional): 
Type of Incident:
Armed (Weapon Displayed)    Armed (Weapon Not Displayed)    Not Armed/Unknown
Weapon:
Pistol Handgun Rifle Shotgun
Knife Bat Chemical Weapon
  Description of Weapon:
Was there a note? Yes No
Describe note:
 i.e., Yellow paper, block lettering, cursive writing, note read, "give me your schedule IIs," etc.
Do police have note? Yes No
Entry Point:
Front Door Rear Door Wall Ceiling
Basement Window Fire Escape
Exit Point:
Front Door Rear Door Wall Ceiling
Basement Window Fire Escape
Entry Type:
Glass Broken Door Forced Door Removed Car Crash
  Other: 

 
Section Two
Cargo Theft
Trucking Company Name: 
Contact Person:  Phone Number: 
Container Number:  Trailer Number: 
Approximate Value of Shipment: 
Owner of the Product: 
Company Representative:  Phone Number: 
Point of Origin:  Point of Destination: 
GPS on Tractor GPS on Trailer GPS on Board with Product
Product Stolen: (Complete the "Items Stolen" section.)

Section Three
Security Devices
Alarm? Yes No
If yes, Audible Silent
Windows Alarmed Exterior Doors Alarmed Motion Detectors Duress (Panic) Button Safe/Vault
Exterior Door Solid Exterior Door Glass Dead Bolt Locks Steel Curtain Inside Steel Curtain Outside
Hidden Camera(s) Visible Camera(s) Camera(s) Interior Camera(s) Exterior Monitors Visible to Public
Still Photos Available Video Available Cellular Phone Backup Notification for Alarm RFID
Battery Back-up for Alarm System Other Devices: 

Section Four
Suspect Information
1.
Suspect Description/Action

(Name (If Known), Role of Suspect, i.e., Held Weapon and Demanded Money/Drugs, Lookout, Accomplice, Appeared to Be in Charge, etc.)
Gender
Male
Female		 Race
Asian
Black
Hispanic
White
Native American
Pacific Islander
Other:  		Age
  		 Height
  		 *Weight
  		 Hair Color
Brown
Black
Blonde
Red
Other:  		Eye Color
Brown
Black
Blue
Green
Hazel
Other: 
 
Facial Hair
 		 Glasses
 		 Hat
 		 Jacket
 Pants
  		 Shirt
  		Shoes
 
Affects: 
(Disguises, Wig, Mask, Ski mask, Bandana, False Beard/Mustache, Sunglasses, Tattoos, Piercings, ... etc.)
2.
Suspect Description/Action
 
(Name (If Known), Role of Suspect, i.e., Held Weapon and Demanded Money/Drugs, Lookout, Accomplice, Appeared to Be in Charge, etc.)
Gender
Male
Female		 Race
Asian
Black
Hispanic
White
Native American
Pacific Islander
Other:  		Age
  		 Height
    		 Weight
  		 Hair Color
Brown
Black
Blonde
Red
Other:  		Eye Color
Brown
Black
Blue
Green
Hazel
Other: 
Facial Hair
 		 Glasses
 		 Hat
 		 Jacket
 		 Pants
 		 Shirt
 		 Shoes
 
Affects: 
(Disguises, Wig, Mask, Ski mask, Bandana, False Beard/Mustache, Sunglasses, Tattoos, Piercings, ... etc.)
3.
Suspect Description/Action

(Name (If Known), Role of Suspect, i.e., Held Weapon and Demanded Money/Drugs, Lookout, Accomplice, Appeared to Be in Charge, etc.)
Gender
Male
Female		 Race
Asian
Black
Hispanic
White
Native American
Pacific Islander
Other:  		Age
  		 Height
  		 Weight
  		 Hair Color
Brown
Black
Blonde
Red
Other:  		Eye Color
Brown
Black
Blue
Green
Hazel
Other: 
Facial Hair
 		 Glasses
 		 Hat
 		 Jacket
 		 Pants
 		 Shirt
 		 Shoes
 
Affects: 
(Disguises, Wig, Mask, Ski mask, Bandana, False Beard/Mustache, Sunglasses, Tattoos, Piercings, ... etc.)

Section Five
Narrative
Describe any part of the reportable event that may help identify the person(s) responsible for this crime. 
(i.e., Suspect was in store for 15 minutes prior to robbery; suspect asked for cough medicine then told employees that this was a robbery; Suspect claimed to be telephone repairman then pilfered items.)

OTC Categories
Feminine Care Family Planning Oral products GI Analgesics
Vitamins Cosmetics Film Batteries Razor Blades
Personal Testing Items Other: 
Please list items below.

Items Stolen
<&# x2F;TR>
Trade name of Substance Controlled Substance Dosage Strength/Form Quantity
Example: Desoxyn Methamphetamine Hydrochloride 5 MG Tablets 3 X 100
Example: Demerol Meperidine Hydrochloride 50 MG/ML Vial 5 X 30ML
*
This information may be shared within the Pharmacy Community.  Yes   No
Fax Copy of DEA-106 to (203) 588 6236
or Mail this form and DEA 106 to: One Stamford Forum, Stamford, CT 06901
ATTN: RxPATROL® Clearing House
Email Contact: RxPATROL@Pharma.com

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