Sample Submission Form

Part A : Customer Details
1.0 Customer Name   2.0 Customer Address
3.0 Contact Person   4.0 Designation
5.0 Contact: Mobile No.   Telephone No.
6.0 Email      
Part B : Product Details
7.0 Product Generic name   8.5 Country of Origin
7.1 Brand Name   8.6 Zimbabwe Registration Number(if any)

7.2 Pharmacological classification

(eg anti-malarial)

  9.0 Sampling Site
8.0 Manufacturer  

9.1 State/Province/City

8.1 Date of Manufacture   9.2 Storage Conditions
8.2 Date of Expiry   Temperature Humidity
8.3 Batch Number   9.3 Sample Size
8.4 Manufacturer Address  

10.0 Transportation conditions

(eg cold chain sample)

Part C : Analysis Required

 

11.0 Chemical Analysis Yes No
Customer Ref No :      

 

Details of Analysis Required (Please tick in the applicable box)

a. Appearance   b. Identity      c. pH d. Assay  
e. Uniformity of Mass f. Dissolution   g. Disintergration h. Uniformity of Content
i. Friability j. Heavy Metals   k. Moisture Content   l. Related Substances
m. Hardness n. Decomposition Products   o. Other test (Please specify)
12.0 Any other Comments
 

 

 
13.0 Microbiology Analysis
Microbiology Analysis Yes No
Customer Ref No :      

 

Details of Analysis Required(Please click in the applicable box)

a. Appearance b. Pyrogen(LAL/BET)  

c. Sensitivity Test

d. Microbial Assay
e.Sterility Test

f. Preservative Efficacy

  g. Microbial Limit (Microbiological Examination of Non-Sterile Products)

 

 
h. Other Test (please specify)   14.0 Any other comments
15.0 Sample Submitted by:
Name   Date