Sample of Security Service Contract by vah11512

VIEWS: 0 PAGES: 2

More Info
									CONTRACT TEST SERVICE
Sample Submission Form

COMPANY NAME:                                                              Laboratory Use Only
CONTACT NAME:                                                              Internal Control Number:     ________-________
NUMBER OF SAMPLES IN SHIPMENT:                                             Customer ID Number:


 Sample                                                Lot              Concentration          Endotoxin         Dose          pH              Storage
 Identification*                                     Number           or Maximum Dose            Limit                                         Temp.**




*If additional space is required, use multiple forms.
** If no storage temperature is indicated, the samples will be stored refrigerated.
TYPE OF SAMPLE
   Biological                   Medical Device                        Water                          Other: ___________________________
   Biotech                      Parenteral                            Tissue                         Serum:             __________
   Chemical                     Pharmaceutical                                                       Controlled Substance                Yes         No
   Intrathecal                  Polymer

TEST TYPE
    Product Characterization                 Validation (Inhibition/Enhancement)                  Release (Limits) - Finished Product
    Method Development                                                                            Release (Limits) - Components/
                                                                                                                     Raw Materials
TEST ASSAY - SELECT ASSAY TYPE
Gel-clot                        Turbidimetric                    Chromogenic                           Chromogenic
   Gel-clot Assay                   Kinetic Assay                    Pyrochrome    ®
                                                                                                           Chromo-LAL Kinetic Assay
   Endotoxin Specific               Endotoxin Specific                   Kinetic Assay                     Glucatell® Kinetic Assay
                                                                                                           (Glucan Specific, Research Use Only)
                                                                          Endotoxin Specific

INSTRUCTIONS
   When sending multiple samples from one lot, indicated the following:        _       Test Samples Individual                  Test Samples Pooled
   For product release, list IC numbers of validations (if known):
   Recommended method for reconstitution or extraction:
   Handling precautions:
   Recommended method of sample disposal:
   Special Instructions:
   Send MSDS for sample (or letter stating handling precautions). If not included, no testing will be performed until received.
   Expedited Services:     Rush test service - 48 hour study initiation (charges are double)                            Yes               No
                           STAT test service - 24 hour study initiation (charges are quadruple)                         Yes               No
Comments




                                                                                                                                          Sample Submission Form
                                                                                                                              Document Number 18101-01 Revision 3
CONTRACT TEST SERVICE
Sample Submission Form
                                                                               Internal Control Number:                                   -

BILLING INFORMATION                                                            REPORTING INFORMATION
Company Name:                                                                  Company Name:
Attention:                                                                     Attention:
Address:                                                                       Address:



                                                                               Phone:
Phone:
                                                                               Fax:
Fax:
                                                                               E-mail:

Please check method of payment:
                                                                               Reports:
Purchase order number:
                                                                               An original report will be sent by mail to the above address. A
Credit card:       Visa       Mastercard         American Express              PDF copy will be emailed upon request.
           Number:
           Security Code:                                                      E-mail (PDF - non encrypted)
           Expiration Date:                                                       Report Only
           Name on Card:                                                          Report and Raw Data
           Signature:


SHIPPING INFORMATION                                                          CONTACT INFORMATION
*Samples should be sent to the following address:                             Phone: 508-540-3444 or 888-232-5889
           Contract Test Service                                              Fax: 508-540-2019
           Associates of Cape Cod, Inc
           124 Bernard E. St. Jean Drive                                      Website: www.acciusa.com/cts
           East Falmouth, MA 02536
*Details for shipping samples can be found in the CTS Pricelist.              Email: testservice@acciusa.com


INTERNAL USE ONLY
Sample/package condition upon receipt:
   Physical condition:                                                                Technician Initials:                 Date:
   Arrival/Storage Temperature:
Number of Samples Received:                                                Agreement with number shipped:            Yes                  No
Sample Status:                Acceptable; no action required.                     Requires Customer Notification
Reason for Notification:         Sample Damaged             Sample lost/missing          Inappropriate storage temperature               Other*
*Explanation:
Customer Contact:                                                  Date:                           Contacted by:
Comments/Resolution:




Action Required:
If additional space is required, attach a separate sheet.                                                        Verified by: ________________
                                                                                                                                   Initial/Date
                                                                                                                                       Sample Submission Form
                                                                                                                           Document Number 18101-01 Revision 3

								
To top