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Summary Report on Dangerous Drug Containing Controlled Chemical
PDEA summary report form for dangerous drug containing controlled chemical
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PDEA Report Form 1-14
Page 1 of __
Summary Report of Transactions on Dangerous Drug and/or Drug Preparations containing Controlled Chemical
(To be submitted by licensed retailers and users for laboratory use/or programs for medical, scientific research or instructional/training purposes)
For the period covering ____________ to ______________
Name of Company/Entity________________________________________________________________
S-License Number__________________________
Address______________________________________________________________________________
Validity __________________________________
Contact details (tel/fax/email)_____________________________________________________________
Name of Drug
(Indicate Dosage Strength and Form)
Beginning
Balance
Total Quantity Received
Purchased
Others
per Supplier
(ex. Return
stocks from
clients)
Total Quantity Disposed
Sold /
Others
Used
(ex. surrender /
return stock to
supplier / loss, etc)
Name of
Supplier
End Balance
Remarks
Note: Fill-out all columns. Indicate n/a if not applicable. Indicate nothing follows after the last drug entry. Summary Report (January to June or July to December) and Register are to be submitted and presented, respectively,
not later than 15days after the covered period. Late submission shall be accompanied by an affidavit stating circumstances of the delay. If report covers more than 1 page, sign all pages.
CERTIFIED TRUE AND CORRECT. FURTHER CERTIFY THAT AFOREMENTIONED END BALANCE TALLIES WITH THE ACTUAL INVENTORY AS OF _____________________________________
________________________________________________________________
Printed name and Signature of Authorized Pharmacist
_____________________________
Date Prepared
NOTED:
____________________________________________________
Printed name, Designation and Signature of Next Higher Ranking Officer
PDEA Report Form 2-14
Page 1 of __
Summary Report of Transactions on Controlled Chemical
(To be submitted by licensed retailers and users for laboratory use/or programs for medical, scientific research or instructional/training purposes)
For the period covering ____________ to ______________
Name of Company/Entity________________________________________________________________
P-License Number__________________________
Address______________________________________________________________________________
Validity __________________________________
Contact details (tel/fax/email)_____________________________________________________________
Name of Chemical
(Indicate CPECs % concentration)
Beginning
Balance
Total Quantity Received
Purchased
Others
per Supplier
(ex. Return
stocks from
clients)
Total Quantity Disposed
Sold /
Others
Used
(ex. surrender /
return stock to
supplier / loss, etc)
Name of
Supplier
End Balance
Remarks
Note: Fill-out all columns. Indicate n/a if not applicable. Indicate nothing follows after the last chemical entry. Summary Report (January to June or July to December, with Distribution report, if applicable) and Register are to be
submitted and presented, respectively, not later than 15days after the covered period. Late submission shall be accompanied by an affidavit stating circumstances of the delay. If report covers more than 1 page, sign all pages.
CERTIFIED TRUE AND CORRECT. FURTHER CERTIFY THAT AFOREMENTIONED END BALANCE TALLIES WITH THE ACTUAL INVENTORY AS OF ______________________________________
________________________________________________________________
Printed name and Signature of Authorized Signatory
_____________________________
Date Prepared
NOTED:
____________________________________________________
Printed name, Designation and Signature of Next Higher Ranking Officer
PDEA Report Form 3-14
Page 1 of __
Summary Distribution Report on Controlled Chemical
(To be submitted by licensed retailers and distributors in addition to the Semi-Annual Report)
For the period covering ____________ to ______________
Name of Company/Entity________________________________________________________________
Address______________________________________________________________________________
Contact details (tel/fax/email)_____________________________________________________________
P-License Number__________________________
Validity __________________________________
Name of Controlled Chemical___________________________________________________
Name of Client
(alphabetically arranged)
EUD
or PDEA
License No.
Address
Total
Quantity Sold
Total Quantity Sold per Month
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
CERTIFIED TRUE AND CORRECT.
________________________________________________________________
Printed name and Signature of Authorized Signatory
_____________________________
Date Prepared
NOTED:
____________________________________________________
Printed name, Designation and Signature of Next Higher Ranking Officer
