Promotional Drug Sample Distribution Record for Pharmaceutical Representatives

Distribution Date and Time

Representative Full Name

Representative Employee ID or Badge Number

Representative Contact Phone Number

Representative Email Address

Representative Geographic Region or Territory

Healthcare Facility Name

Facility Type

Facility Complete Address

Specific Department or Ward Receiving Samples

Is this the first time distributing samples to this specific department at this facility?

Please provide details on how this new department was identified and onboarded according to company protocol:

Purpose of This Distribution Visit

Date of Previous Visit to This Facility (if applicable)

Receiving Healthcare Professional Full Name

Professional Title or Credential

Primary Medical Specialty or Practice Area

Professional License Number

License Issuing Authority or Regulatory Body

Professional License Expiry Date

Has the professional license been independently verified through the issuing authority's official database within the last 30 days?

Explain why license verification was not completed and describe the alternative verification process used:

Is the healthcare professional currently affiliated with this facility according to official records?

Provide explanation of the professional's relationship to the facility and any supporting documentation references:

Types of Samples Authorized to Receive (based on license scope)

Has this healthcare professional received promotional samples from your company within the last 12 months?

Approximately how many distribution events have occurred with this HCP in the past 12 months?

Has the healthcare professional disclosed any potential conflicts of interest or prescribing restrictions?

Describe the disclosed conflict or restriction and how it was addressed per company policy:

Upload scanned copy or digital photograph of the healthcare professional's government-issued photo ID and professional license (both sides if applicable)

Detailed Sample Distribution Inventory

Total Number of Distinct Products Distributed

Total Aggregate Value of All Samples Distributed

Do any of the distributed samples contain controlled substances or require special handling under national regulations?

Specify the controlled substance schedule or special handling requirements and confirm additional security measures taken during transfer:

Were any samples distributed that are considered investigational or not yet approved for general marketing?

Provide the investigational product protocol number and confirm that appropriate informed consent and safety monitoring procedures were explained to the HCP:

Additional Product-Specific Notes or Instructions Provided to Healthcare Professional

Upload photographs of product packaging showing batch numbers and expiry dates for verification

I confirm that this sample distribution complies with all applicable national and international pharmaceutical marketing codes, including but not limited to IFPMA, PhRMA, and EFPIA guidelines.

I confirm that no cash, cash equivalents, or personal gifts were offered or exchanged in conjunction with this sample distribution.

I confirm that the quantity of samples distributed is reasonable and appropriate for the stated clinical evaluation purpose and does not exceed institutional or regulatory limits.

Does the healthcare facility have a written policy regarding acceptance of promotional samples?

Summarize the facility's policy and confirm that this distribution adheres to all stated requirements:

Were samples transferred directly to a secure, restricted-access storage area within the facility (e.g., pharmacy, locked cabinet)?

Describe the alternative secure storage arrangement and why direct transfer to standard secure area was not possible:

Do any samples require cold chain or temperature-controlled storage (2-8°C or other specific range)?

Confirm that temperature-controlled storage was available and that temperature monitoring devices or logs are maintained. Provide storage unit identifier:

Has the healthcare professional completed your company's training module on appropriate sample handling, anti-diversion measures, and patient safety within the last 24 months?

Explain plan to ensure training completion and interim safeguards communicated to HCP:

Were there any irregularities, concerns, or suspicious requests observed during this distribution event?

Describe the irregularity or concern in detail and outline immediate actions taken or planned:

Result of This Distribution Event

Additional Compliance Notes or Observations

Was the receiving healthcare professional physically present and available to sign for the samples at the time of distribution?

Describe the alternative authorized receiver and their relationship to the named HCP, including verification of delegation authority:

Healthcare Professional Digital Signature - By signing, I acknowledge receipt of the enumerated samples, confirm my license status, and agree to store and handle these products according to regulatory requirements and institutional policy.

Signature Timestamp (automatically generated upon signing)

Identity Verification Method Used at Time of Signature

Did a third-party witness observe the signature and verification process?

Witness Full Name and Title

Optional: Upload photograph of signed physical receipt or HCP holding samples for additional verification (ensure no patient-identifiable information is visible)

I confirm that the digital signature process used meets all legal requirements for electronic signatures in the jurisdiction where this distribution occurred.

Any Technical Issues or Anomalies Encountered During Digital Signature Process