This section captures the essential details of the pharmaceutical representative conducting the distribution and the healthcare facility receiving the samples. Accurate information ensures proper accountability and traceability in the pharmaceutical supply chain.
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
North America
Europe
Asia-Pacific
Latin America
Middle East & Africa
Other
Healthcare Facility Name
Facility Type
Hospital
Private Clinic
Medical Center
Academic Medical Institution
Community Health Center
Specialty Practice
Research Institution
Other
Facility Complete Address
Specific Department or Ward Receiving Samples
Is this the first time distributing samples to this specific department at this facility?
Purpose of This Distribution Visit
Routine Promotional Sample Drop
New Product Introduction
Clinical Trial Recruitment Support
Educational Program Support
Conference or Event Follow-up
Peer Discussion Sample Provision
Other
Date of Previous Visit to This Facility (if applicable)
Comprehensive verification of the receiving healthcare professional's credentials is critical to ensure samples are distributed only to authorized, licensed practitioners. This section establishes legal eligibility and helps prevent diversion to unauthorized individuals.
Receiving Healthcare Professional Full Name
Professional Title or Credential
Medical Doctor (MD)
Doctor of Osteopathic Medicine (DO)
Registered Nurse (RN)
Nurse Practitioner (NP)
Physician Assistant (PA)
Pharmacist (PharmD/RPh)
Dentist (DDS/DMD)
Other Licensed Prescriber
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?
Is the healthcare professional currently affiliated with this facility according to official records?
Types of Samples Authorized to Receive (based on license scope)
Prescription Medications Only
Over-the-Counter Products Only
Both Prescription and OTC
Controlled Substances (if permitted)
Investigational Medicinal Products
Medical Devices
Other
Has this healthcare professional received promotional samples from your company within the last 12 months?
Has the healthcare professional disclosed any potential conflicts of interest or prescribing restrictions?
Upload scanned copy or digital photograph of the healthcare professional's government-issued photo ID and professional license (both sides if applicable)
Precise documentation of each sample distributed is essential for regulatory compliance, inventory management, and potential product recall traceability. This section requires granular detail for complete accountability of promotional materials transferred to the healthcare provider.
Detailed Sample Distribution Inventory
Distribute This Item | Product Brand or Generic Name | Dosage Form and Strength | Quantity of Units Distributed | Batch or Lot Number | Product Expiry Date | Estimated Retail Value per Unit | Total Item Value | Storage Condition Requirement | Sample Distribution Purpose | |
|---|---|---|---|---|---|---|---|---|---|---|
CardioMax 20mg | Tablet, 20mg | 30 | BATCH-2024-8847 | 8/15/2026 | $8.50 | $255.00 | Room Temperature 15-25°C | Patient Evaluation | ||
GlucoControl 5mg | Tablet, 5mg | 0 | BATCH-2024-9123 | 12/31/2026 | $12.75 | $0.00 | Room Temperature 15-25°C | Clinical Familiarization | ||
$0.00 | ||||||||||
$0.00 | ||||||||||
$0.00 | ||||||||||
$0.00 | ||||||||||
$0.00 | ||||||||||
$0.00 | ||||||||||
$0.00 | ||||||||||
$0.00 |
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?
Were any samples distributed that are considered investigational or not yet approved for general marketing?
Additional Product-Specific Notes or Instructions Provided to Healthcare Professional
Upload photographs of product packaging showing batch numbers and expiry dates for verification
This section ensures adherence to global pharmaceutical marketing codes, anti-bribery regulations, and institutional policies. All statements must be affirmed to maintain ethical standards and legal compliance in promotional activities.
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?
Were samples transferred directly to a secure, restricted-access storage area within the facility (e.g., pharmacy, locked cabinet)?
Do any samples require cold chain or temperature-controlled storage (2-8°C or other specific range)?
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?
Were there any irregularities, concerns, or suspicious requests observed during this distribution event?
Result of This Distribution Event
Successfully Completed
Partially Completed - Storage Issues
Partially Completed - HCP Availability
Deferred - Verification Required
Deferred - Policy Review Needed
Cancelled - Compliance Concerns
Other
Additional Compliance Notes or Observations
Final verification and acknowledgment by the receiving healthcare professional is mandatory to confirm receipt, understanding of appropriate use, and commitment to secure handling. Digital signature and identity verification ensure non-repudiation and complete audit trail.
Was the receiving healthcare professional physically present and available to sign for the samples at the time of distribution?
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
Government-Issued Photo ID Inspected
Biometric Verification
Facility Badge with Photo Verified
Two-Factor Authentication via Mobile
Witnessed by Authorized Third Party
Digital Certificate Authentication
Other
Did a third-party witness observe the signature and verification process?
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