SAMPLES REPOSITORY OFFICE Sample Receipt Form-Medical Devices (Page 1 of 3 to be completed in duplicate)
Part A: Customer Details · Part A: Customer Details
1. Customer Name: _______________________________________________________________ 2. Customer Address: _____________________________________________________________ _________________________________________________________________________ 3. Contact Person: _______________________ 4.Designation:_______________________ 5. Contact Telephone No._________________ 6. E-mail: __________________________ 7. Sample Submitted By: Name: ________________ Signature: _________________ Date____________ Time__________
Part B: Product Details · Part B: Product Details
8. Date Sample Submitted:_________________________________________________________ 9. Sample Classification _________________________________________________________ 10. Product Names: Brand: _______________________________________________________ Type: ________________________________________________________ 11. Manufacturer:________________________________________________________________ 12. Country of Origin:_____________________________________________________________ 13. Product license Number:________________________________________________________ 14. Package Size________________________________________________________________ MCAZ Batch Date of Date of Sample Container Label Sample Ref Number manufacture Expiry size Status appearance storage conditions
PART C: TERMS AND CONDITIONS · PART C: TERMS AND CONDITIONS
1. Privacy and Confidentiality 1.1 The MCAZ laboratory recognizes the importance of privacy and shall be responsible for the management of all information obtained or created during the performance of laboratory activities. 1.2 The MCAZ laboratory shall hold the information disclosed to it in strict confidence and shall use the confidential information only for testing activities. 1.3 The MCAZ laboratory shall exercise reasonable care to protect your information including your test data and results from unauthorized use and disclosure. 1.4 The MCAZ Laboratory shall not, without your prior written consent, disclose your Confidential Information to any person, party or entity except to such of its representatives who need such information to perform duties connected with the testing activities, and who are bound by an obligation of confidentiality consistent with these terms and conditions. 1.5 For purposes of these terms and conditions, “Representatives” means MCAZ Laboratory’s officers, employees, partners, agents or other representatives (including, without limitation, its attorneys, accountants, auditors, assessors, consultants and financial advisers). 1.6 Exceptions: MCAZ Laboratory shall not be liable for disclosure or use of Confidential Information that: 1.6.1 at the time of disclosure was in the public domain, or subsequently became part of the public domain otherwise than by breach of these terms and conditions; 1.6.2 you authorized in writing to be disclosed; or 1.6.3 is being disclosed in compliance with a Court Order or an order of any other competent body, or as required by the Medicines and Allied Substances Control Act (Chapter 15:03) or any other law, provided that the MCAZ laboratory shall first give you written notice of such disclosure and further provide that the MCAZ laboratory limits the disclosure to the least that is legally required. 2. Process requirements 2.1 In the event that you request a statement of conformity to a specification or standard for the test (e.g. pass/fail, complies/does not comply) the MCAZ Laboratory, shall use the defined specification as stated in the method used to conduct the test. However, where a non-standard method is used, the decision rule will apply. MCAZ laboratory shall communicate to you the decision rule selected upon submission of the test results. By signing below you agree to the terms and conditions stated above. ---------------------------- ------------------------------------------ ---------------- Signature Printed name Date
PART D: FOR MCAZ USE ONLY · PART D: FOR MCAZ USE ONLY
Sample Received by: Name _____________ Signature_________________ Date____________ Sample Forwarding Destination / Unit __________________________________________________________________ Forwarded by ______________ Date _______________ Time ____________________ Signature Received by ________________ Date _______________ Time ____________________ Signature