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Internal Form
Chain Of Custody
Product Name:
Lot Number:
Batch Number:
Form
API
Pill
Powder
Vial
Capsule
Topical
Inhaler
Suppositorie
Transdermal patche
Injectable
Manufacturer
Date and Time of Sampling (if applicable)
MM slash DD slash YYYY
Testing Results (if applicable)
N/A
Pass
Fail
Temperature
Room temperature: 15-25°C (59-77°F)
Refrigerated: 2-8°C (36-46°F)
Frozen: -20°C (-4°F) or below
Human / Veterinary
Human
Veterinary
Sterility
Sterile
None Sterile
Manufacturing Date:
MM slash DD slash YYYY
Expiration Date:
MM slash DD slash YYYY
Distribution History:
Sold To
Quantity
Shipment Date:
MM slash DD slash YYYY
Shipment Method
Air
Ground
Sea
Delivery Date:
MM slash DD slash YYYY
Wight
Temperature Log Number
Signed By
Sold To
Quantity
Shipment Date:
MM slash DD slash YYYY
Shipment Method
Air
Ground
Sea
Delivery Date:
MM slash DD slash YYYY
Wight
Temperature Log Number
Signed By
Document Number:
Document Revision Number
Effective Date:
MM slash DD slash YYYY
Storage Temperature Log Number
Signed By
