MAINE DMDC DATA SUBMISSION FORM Submitting Company Person Responsible for Report Submission

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MAINE DMDC DATA SUBMISSION FORM Submitting Company Person Responsible for Report Submission Powered By Docstoc
					MAINE DMDC DATA SUBMISSION FORM
                                                        Submitting Company:
                                   Person Responsible for Report Submission:
                          Title of Person Responsible for Report Submission:
                                                             Address Line 1:
                                                             Address Line 2:
                                                                       Phone:
      Aggregate cost of employees engaged in promotional actitivies in Maine:
Labeler Number Manufacturer Value Nature Description of Nature Purpose Description Recipient credentials Recipient Last name Recipient First name Recipient detail Facility Date
Labeler Number        Legal Labeler Number that you are reporting on

Manufacturer          Legal Manufacturer name associated with labeler

                                                                          Dollar amount of worth/value of item, gift,
                                                                          expense, fee, donation, contractor fee
                                                                          or payment. This filed will only hold
Value                 $0.00                                               dollar value.

                                                                          A tangible item can be described in the
Nature                Gift                                                description box
                      Cash
                      Check
                      Donation
                      Food
                      Grant
                      Lodging
                      Transportation

Description Of Gift   Describe gift items ex: book, pens, Donation to..

                                                                          All expenses associated with advertising, marketing
                                                                          and direct promotion of prescription drugs through
                                                                          radio, television, magazines, newspapers, direct mail
                                                                          and telephone communications made to residents of
                                                                          this State, including payments or grants directed to
Purpose               Advertising                                         or earmarked for use in Maine

                                                                                                                                  Printing costs of patient education materials
                                                                          Support for independent or continuing medical           and disease management materials distributed
                                                                          education programs (IME or CME) to the                  to such persons and entities. Design and
                                                                          extent of participation by such persons and             other production costs also must be reported
                                                                          entities, including payments to medical education       for materials designed specifically for Maine
                      Education                                           companies                                               users

                                                                          Payment of consulting fees and expenses                 Payments made directly or indirectly to such
                                                                          directly or indirectly to such persons and              persons or entities for writing articles or
                      Consulting Fees                                     entities, subject to exceptions in Section 2.05         publications
               Payments made directly or indirectly to such
               persons and entities for participation in
               speakers’ bureaus and honoraria or other
               payments for time while speaking at or attending
Speaker Fees   meetings, lectures or conferences
               Charitable grants, either directly or earmarked, to
Grants         such persons and entities, even if unrestricted
               Payments made directly or indirectly to such persons
                or entities in connection with market research
               surveys or other activities undertaken in support of
Survey         developing advertising and/or marketing strategies



                                                                      The Department will treat gifts to an office or
                                                                      office staff as gifts to the prescriber, clinic or
                                                                      facility. If the gift is a sixty dollars ($60)
                                                                      luncheon for an office of three physicians and
               valued at more than twenty-five dollars ($25) per      three non-prescribing office staff, the gift
               day, and anything provided to such persons or          amount shall be attributed in whole to the clinic
Gift           entities for less than market value.                   or facility and is reportable



                                                                      The Department will treat Food to an office or
                                                                      office staff as food to the prescriber, clinic or
                                                                      facility. If the food is a sixty dollars ($60)
                                                                      luncheon for an office of three physicians and
               valued at more than twenty-five dollars ($25) per      three non-prescribing office staff, the food
               day, and anything provided to such persons or          amount shall be attributed in whole to the clinic
Food           entities for less than market value.                   or facility and is reportable
                                                                                                      The Department will treat entertainment to an
                                                                                                      office or office staff as entertainment to the
                                                                                                      prescriber, clinic or facility. If the
                                                                                                      entertainmentis a sixty dollars ($60) movie for
                                                                                                      an office of three physicians and three non-
                                              valued at more than twenty-five dollars ($25) per       prescribing office staff, the entertainment
                                              day, and anything provided to such persons or           amount shall be attributed inwhole to the clinic
                       Entertainment          entities for less than market value.                    or facility and is reportable
                                              Costs of trips and travel provided to such persons
                       Travel                 or entities not employees
                                              Costs of product samples provided to such persons
                                              or entities, except for samples and starter kits that
                       Samples                will be distributed free of charge to patients
                                              Costs of free or in-kind services provided
                       Free Services          to such persons or entities

Date of Payment        mm/dd/yyyy             Format must be exact

                                              Do not abbriviate credentials in this column. You
                                              may do this in the description column. Use only
Credentials            Primary Care Doctor    the list provided here.
                       Nurse
                       Specialist Doctor
                       General Public
                       Pharmacist
                       Nurse Practioner
                       Physicians Assistant
                       Psychiatrist

Recipient Last name                           Last Name only, no credentials

Recipient First name                          First Name only, no credentials
                                                                                                                For example Dr. John Doe Office has 3 nurses
                                                                                                                and 2 Office personel plus the Dr. List the Dr.'s
                                                                                                                name as Recipient and his credentials, do Not
                                                                                                                list the rest ofthe staff. You can put doctors
                                                      If the service is for multile recipients at a location,   office in this field
Facility   Hospital                                   Name only the facility type and one recipient name.       instead.
           Clinic
           Doctors Office
           University (college, school, university)
           Association

				
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