Free 0421 - Federal

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A. B.

1. STORAGE LOCATION C. D.

2. NAME OF PRODUCT 4. NAME AND ADDRESS OF RESPONSIBLE FIRM

3. SAMPLE NO.

CR X / DEA SPL SPLIT SAMPLE

5. DATE SAMPLE RECEIVED 8. METHOD OF SHIPMENT 9.
A. PERSONALLY FROM B. VIA
PP BUS

6A. BY WHOM RECEIVED
C. SHIPPED FROM D. B/L NO.
FREIGHT AIR

6B. DIST /DIV

7. DATE RECORDS REC'D

NUMBER SHIPPING CONTAINERS DESCRIPTION B. NUMBER SAMPLE OF PACKAGES SHIPMENT C. COPY IN FULL SEAL INSCRIPTION A.

TYPE SIZE, TYPE, ETC.

CONDITION CONDITION CONDITION

DATE

10. SAMPLE DELIVERY AMOUNT FROM

TO

DATE

11. SAMPLE RETURNED AMOUNT

TO

FROM

12. SAMPLE A. DATE SDN DISPOSITION
FORM FDA 421 (7/03) (2 PART)

B. DATE DESTROYED

C. DESTRUCTION METHOD

D. AMOUNT DESTROYED E. BY WHOM F. REASON

Continue on reverse; also record on reverse details for which space is lacking above

SAMPLE ACCOUNTABILITY RECORD
PSC Graphics: (301) 443-1090 EF

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Hold sample until SAMPLE NO.

1. 2. 3.

NAI by home district. NAI by examining laboratory (30-day grace period expired). Legal or other action closed. (Describe)

Reverse of FDA 421 (7/03)