HHS - LAW ENFORCMENT INCIDENT REPORT

LAW ENFORCEMENT INCIDENT REPORT

NORTH DAKOTA HEALTH & HUMAN SERVICES

MEDICAL MARIJUANA PROGRAM

SFN 61541 (12/2022)
Law Enforcement/Reporter Information
Law Enforcement Name*
Law Enforcement Agency Name*
Law Enforcement Badge ID Number*
Law Enforcement Report/Incident Number
Telephone Number*
Registered Patient, Caregiver or Agent Information
Name*

First NameLast Name
Address*

CityState / Province

Postal / Zip Code
Registry Identification number (if known)
Telephone Number
Date of Birth*
Other Parties Involved (If more than one other party is involved, please provide additional names and information in the "reason for Report" section of this form)
Other Parties Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth
Telephone Number
Please enter a valid phone number.
Reporting Checklist (check all that apply) Registry Identification cardholders include: patients, designated caregivers, manufacturing facility agents, dispensary agents and laboratory agents)
Possession of usable marijuana, medical marijuana waste, or laboratory samples, as part of the North Dakota Medical Marijuana Program, without a valid registry identification card.Possession of more than 3 ounces of dried leaves or flowers (7.5 ounces for patient with an enhanced amount), dispensed through the North Dakota Medical Marijuana Program, by a registered qualifying patient or registered designated caregiver. (A designated caregiver may have up to 3 ounces, or 7.5 ounces when enhanced amount is authorized, per qualified patient.Valid registry identification cardholder in possession of another patient's usable marijuana dispensed through the North Dakota Medical Marijuana Program.Transfer of, or attempt to transfer, a registry identification card to another person.Other
Reason for Report: (Who, What, When, Where , Why, How Often)*
Law Enforcement Signature *
Your typed signature will suffice for electronic
Date*

MonthDayYear
Should be Empty:

Law Enforcement/Reporter Information

Registered Patient, Caregiver or Agent Information

Other Parties Involved (If more than one other party is involved, please provide additional names and information in the "reason for Report" section of this form)

Reporting Checklist (check all that apply) Registry Identification cardholders include: patients, designated caregivers, manufacturing facility agents, dispensary agents and laboratory agents)