HHS - LAW ENFORCMENT INCIDENT REPORT

Law Enforcement Incident Report

North Dakota Health and Human Services

Medical Marijuana Program

SFN 61541 (10/2026)
Law Enforcement/Reporter Information
Law Enforcement Name
Law Enforcement Agency Name
Law Enforcement Badge ID Number
Law Enforcement Report/Incident Number
Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Registered Patient, Caregiver or Agent Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registry Identification Number (if known)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reporting Checklist: Registry Identification cardholders include patients, designated caregivers, manufacturing facility agents, dispensary agents and laboratory agents
Check all that apply

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.) Edibles possession limit is 500 mg THC.Other
Reason for Report: (Who, What, When, Where , Why, How Often)
Law Enforcement Signature
Your typed signature will suffice for electronic
Date
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: Registry Identification cardholders include patients, designated caregivers, manufacturing facility agents, dispensary agents and laboratory agents