Effective Date: 16-Aug-2018 SOP QC-045-F04 v2

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Sample Collection Form

Description Enema, Rectal Spring Valve, Assembly Lot Number 20268
Code 600016 CS Number N/A

Initial Evaluation: N/A

The supplier/manufacturer name, part number and Acceptable
material name on the CoA or CoC matches the Issue Noted:
approved specification

Sample Type N/A Routine Challenge Retest

AQL Normal Tightened Reduced
Initial/Date:

Container Evaluation: N/A

Overall appearance ☐ Acceptable
☐ Issue Noted:
Integrity of container seals ☐ Acceptable
☐ Issue Noted:
Labeling and code conforms to CoA or CoC and ☐ Acceptable
specification ☐ Issue Noted:
Supplier/manufacturer’s lot number matches CoA ☐ Acceptable
or CoC and specification ☐ Issue Noted:
Quantity Sampled
QC/QA sample 315 Spring Valve Assemblies/79 asssemblies from 3 boxes/78 assemblies from 1
box__________________________________________________ N/A
Retain sample __________________________________________________ N/A
Outside testing __________________________________________________ N/A
Micro sample __________________________________________________ N/A
Comments:

Sampled By: Date:

Received By: Date:

This is a Level 2 Form Print Date 29-Aug-2018

Effective Date: 16-Aug-2018 SOP QC-045-F04 v2
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This is a Level 2 Form Print Date 29-Aug-2018