Operator:
Name: .............................................................................................................................................. |
Address: ........................................................................................................................................... |
Name of the responsible medical director/pharmacist: ...................................................................... |
Title: ................................................................................................................................................. |
Phone No ...............................................................Fax No .............................................................. |
Requests the supplier:62
62 If the operator is exporting directly from its emergency stock, it should be considered as a supplier.
Name: .............................................................................................................................................. |
Address: ........................................................................................................................................... |
Responsible pharmacist:: ................................................................................................................. |
Title: ................................................................................................................................................. |
Phone No ...............................................................Fax No .............................................................. |
For an emergency shipment63 of the following medicine(s) containing controlled substances:
63 Emergency deliveries do not affect the estimate of the recipient country since they have already been accounted for in the estimate of the exporting country.
Name of product (in INN/generic name) and dosage form, amount of active ingredient per unit dose, number of dosage units in words and figures
Narcotic medicines as defined in the 1961 Convention (e.g. morphine, pethidine, fentanyl) [e.g.morphine injection 1 ml ampoule; morphine sulfate corresponding to 10 mg of morphine base per ml; two hundred (200) ampoules]
......................................................................................................................................................... |
......................................................................................................................................................... |
......................................................................................................................................................... |
......................................................................................................................................................... |
......................................................................................................................................................... |
Psychotropic substances as defined in the 1971 Convention (e.g. buprenorphine, pentazocine, diazepam, phenobarbital)
......................................................................................................................................................... |
......................................................................................................................................................... |
......................................................................................................................................................... |
......................................................................................................................................................... |
......................................................................................................................................................... |
Others (nationally controlled in the exporting country, if applicable)
......................................................................................................................................................... |
......................................................................................................................................................... |
To the following recipient (whichever applicable):
Country of final recipient: .................................................................................................................. |
Responsible person for receipt: ........................................................................................................ |
Name: .............................................................................................................................................. |
Organization/Agency:........................................................................................................................ |
Responsible pharmacist:: ................................................................................................................. |
Address:............................................................................................................................................ |
Phone No ...............................................................Fax No .............................................................. |
For use by/delivery to:
Location: ................................ |
Organization/Agency |
................................................................... |
............................................... |
|
................................................................... |
............................................... |
|
................................................................... |
Consignee (If different from above e.g. transit in a third country): |
Name: .................................... |
Organization/Agency |
................................................................... |
Address:............................................................................................................................................. |
Phone No ...............................................................Fax No ............................................................... |
Nature of the emergency (Brief description of the emergency motivating the request):
......................................................................................................................................................... |
......................................................................................................................................................... |
......................................................................................................................................................... |
Availability of, and action taken to contact the control authorities in the receiving country:
......................................................................................................................................................... |
......................................................................................................................................................... |
I certify that the above information is true and correct. My Organization will:
♦ Take responsibility for receipt, storage, delivery to the recipient/end-user, or use for emergency care (strike out what is not applicable) of the above controlled medicines;
♦ Report the importation of the above controlled medicines as soon as possible to the control authorities (if available) of the receiving country;
♦ Report the quantities of unused controlled medicines, if any, to the control authorities of the receiving country (if available), or arrange for the end-user to do so (strike out what is not applicable).
Title: ........................................................Date: ................................................................................. |
Location: ................................................... |
|
............................................................................... |
| |
|
(Signature) |
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