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Download Investigational Agent Disposition Record (Return/Destruction Log) Use a separate form for
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UCDHS Pharmaceutical Services Investigational Drug Service Investigational Agent Disposition Record IRB #: ____________ Use a separate form for each individual study (Return/Destruction Log) Study Name: Sponsor & Protocol #: Investigator and/or Contact Person: Date Quantity Agent Name, Dose Form and Strength Reason for Return (expired drug, study closed, pt returns) Manufacturer __________ (record the kit #, bottle #, etc. on back or below) Disposition: Destroyed __________ Lot No. Returned ________ Address, if returned: ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Shipped via: FedEx ________ UPS: ________ Notes: _____________________________________________________ Date shipped: ______________ ________________________________________________ Signature of Technician __________________ Date _______________________________________________ Signature of Pharmacist __________________ Date _______________________________________________ Sponsor’s Representative __________________ Date S:\AC\Pharmacy\IDS\IDS\Forms and Worksheets\Return or Destroy .doc Recorder’s Initials
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