SAMPLE DESTRUCTION REQUEST FORM
Click Here For Detailed Instructions
This form will serve as evidence of the request and as a Certificate of Destruction upon completion of destruction services.
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Fields outlined in red are required and are necessary for this request to be processed.
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A. Study Details
Sponsor
Protocol Number
PPD Study Code
B. Sample Details
This form requires attachment of an Excel Destruction Sample Listing. There is a
Open/Close Attachments Panel
template in the attachments panel. Download and Complete the template with relevant
sample data for samples to be destroyed. There is a 25,000-sample maximum per
Click Here To Open/Close Attachments Panel
request.
Use Button Below To Add Attachments
Click Here to Attach Sample List, Wet Signature Page, Etc.
C. Requester Information
Requester Name
Request Date
Telephone#
(w/Country Code)
Requester Email
Destruction Reason
Destruction Target TAT
1 Calendar Month
Check if the Requester is also the Sponsor
Check if Wet Signature Page used instead of digital signature
Please use the selection tool at the top of this page to copy the auto-generated filename below and 'Save As' this file to a local drive on your computer
Requester’s
Digital Signature:
Submit
to GCL
Project
Assistants
Click to Submit
Form
to PPD
GCL
Project Assistants
D. PPD Central Lab-BioA Review/Approval
PA/PI/PM signatures below certify that this request and attached sample listing has been fully reviewed and confirm that the sample(s) indicated herein may be DESTROYED.
PA Name
PM Name
Samples at BioA?
PA Comments
PA DocuSign
PA Submit
Submit to BioA
PA Review →
(GCL)
PA Email
PI (or designee)
BioA Review →
PM Email
Select...
Submit to PM
PI Name
PI Disposition
PI Comments/Assist Codes
PI Email
Select...
PM Comments
PI DocuSign
PI Submit
Submit to PM/PMA
Sponsor’s Email
PM Review →
(GCL)
PM DocuSign
PM Submit
Submit to Sponsor
Submit to SM
E. Sponsor Approval
Sponsor’s signature below certifies that this request and attached sample listing has been fully reviewed and confirm that the sample(s) indicated herein may be DESTROYED.
Check if Wet Signature Page used instead of digital signature
Sponsor’s Name
Sponsor’s Email
Sponsor’s Digital Signature
Submit to GCL Destructions Team
Submit to GCL Destructions Team
SM Approver Name
F. PPD Central Lab Sample Management Approval
Authorization Date
3-Digit Study Code
SM DocuSign
G. PPD Central Labs Destruction Certification
This section is to certify that the samples described herein have been destroyed. The samples will no longer be available for testing or services of any kind.
Select A Location...
Select A Location...
Select A Location...
Select A Location...
Select A Location...
Laboratory Specific Destruction Certificate Numbers
PLEASE NOTE: PPD Bioanalytical Laboratories (PPD BioA) are subject to different regulatory standards (e.g. GLPs) than PPD Global Central Labs and have standalone Standard Operational Procedures (SOPs) covering the disposal of pre-clinical and
clinical trial related specimens. As such, PPD BioA Sample Management Departments should be contacted directly at either – DemingWaySampleMgmnt@ppdi.com (BioA Middleton) or Richmond_Sample_Management@ppdi.com (BioA Richmond) – to
obtain specimen disposal tracking data relating to disposals processed exclusively in their database (i.e. Assist LIMS).
NA
NA
NA
NA
NA
Destroyed By:
Destroyed By:
Destroyed By:
Destroyed By:
Destroyed By:
NA
NA
NA
NA
NA
Destroyed On:
Destroyed On:
Destroyed On:
Destroyed On:
Destroyed On:
Staff 1 DocuSign:
Staff 2 DocuSign:
Staff 3 DocuSign:
Staff 4 DocuSign:
Staff 5 DocuSign:
A-F TAT (days)
0
F-G TAT (days)
0
GCL-SM-0024br04, Effective 01MAR2020
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