This Section for ChRi Laboratories Use Only
Request Number:
PRFPurchase Order Number
Account No:
Project Code:
Date Received:
Initial Reviewed by:
Results Transmission:
Email
Fax
US Mail
Project Request Form
Ship Samples to:
ChRi Laboratories Inc
1000 Westgate Dr. Suite 241
St. Paul, MN, 55114
Send Report To:
Send Invoice To:
Client Project Manager:
Phone Number:
E-mail Address:
Fax Number:
Company Name:
Address:
City:
State:
Zip Code:
Country:
Data to be Used for Regulatory Submission?
Billing Contact:
E-mail Address:
Quote # (if applicable):
Fax Number:
Company Name:
Address:
City:
Zip Code:
Request Date:
Yes
No
Same as Send Report To
Q
State:
Country:
Due Date:
Sample and Test Information
Describe Sample
1.
2.
3.
4.
5.
6.
ID
Amount
Test Code*
* Test Code: See General Service Options section.
Please provide additional details on work required: (Provide details for Test Code 42. Specify additional attachments):
Safety and Handling Instructions (Shipping, Storage, Disposition, etc)
Safety Information:
Sample Storage:
Sample Disposition:
Container
Non-Hazardous,
Hazardous,
Biohazard,
Flammable,
Potent Compound
Ambient Temp.,
Refrigerate (2-8 oC),
Freezer (-10 to -25 oC),
Light Sensitive
Discard,
Return,
Return
MSDS Attached?
Yes
No
Other Information Needed
Regulatory Significance:
Early Feasibility/R&D
In Process Testing
Method Development Required?
Method Validation Required?
Method Transfer Required?
Use Compendia Method?
Clearance (API, RM)
Toxicology Studies
Clinical Studies
Early Pilot Studies
Product Development
Product Release
Yes
No Client Supplied Method Attached?
Yes
Yes
No Training on Client Method Required?
Yes
Yes
No Test Specification(s) Attached?
Yes
Yes
No Client Supplied Reference Material?
Yes
Requestor Name:
FRM-009, REV 1.0, 27 DEC 2010
Requestor Signature:
www.chrilabs.com
(612) 454 1523
Date:
2/9/2016 3:17 AM
Page 1 of 2
No
No
No
No
General Service Options
Test
Test Code
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
Method Development
Method Validation
Method Transfer/Crossover
Site Qualification Support
Method Equivalency Studies
Historic Method Validation
Reference Material Qualification/Retest
Assay by HPLC
Content Uniformity
GC Analysis
Residual Solvent Analysis by GC
Solvent Purity by GC
Related Substance Isolation
Related Substance Characterization
Related Substance Identification
Drug Product Characterization
Karl Fischer Moisture Content
Percent Solids
Melting Point
Residue On Ignition
TLC
Test
Test Code
USP Dissolution Studies
Release Rate Studies
LC/MS Analysis
GC/MS Analysis
Identification by FTIR
Troubleshooting by FTIR
Quantitative FTIR
Ion Exchange Chromatography
Degradation Chemistry
Container Closure Studies
API Solubility Studies
API Intermediates Characterization
Polymorph Screening & Characterization
API Re-crystallization Studies
API or Raw Material Clearance
Stability Studies
Stability Storage and Monitoring Only
Photostability Studies
Leachables/Extractables
OOS/OOT Investigation
Special Request (e.g. Early Pilot Studies)
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
Additional Stability Testing Information (Check all that apply)
ICH Stability Studies
ICH Photostability Studies
Write Stability Protocol
Shelf-Life Evaluation & Report
Annual Commitment
Storage Conditions:
25oC/60%RH,
Issue COA after each Pull Point
Write CMC Stability Section
Non-formal Stability Studies
40 oC/75%RH,
Other
Annual Stability Report(s)
Troubleshooting Stability Data
Final Report Options (Check all that apply)
Certificate of Analysis
Brief Report (Excel Spreadsheet, Summary Tables, etc)
Full Technical Report
Method Validation/Verification Protocol and Report
Qualification Protocol and Report
Please provide additional details about report required:
Test Method Instructions
Method Development Report
Method Transfer Protocol and Report
Attach Chromatograms, Scans, Thermographs, etc.
Attach Raw Data Files
Please Note: A copy of the completed and signed Request Form must be submitted with samples
Requestor Name:
FRM-009, REV 1.0, 27 DEC 2010
Requestor Signature:
www.chrilabs.com
(612) 454 1523
Date:
2/9/2016 3:17 AM
Page 2 of 2