Handling, Storing, Packaging, Protecting and Delivering Novo Nordisk products 1 of 2

Appendix 3: Transport temperature deviation report form (2

pages)
Please send this form with documentation (see section 3) to DFPQS by e-mail to
FP-TRANS-DEV@novonordisk.com or fax +45 4442 7430.

Please use BLOCK CAPITALS if you fill in by hand.

Information on shipment
Invoice no: Local ref no:
Date and time of removing temperature / /201 (day/month/year)
recorders and placing the products in cold ____:_____ (hours:min) (24 hrs clock)
storage:
Date you discovered deviation: / /201 (day/month/year)
Does Novo Nordisk own the products? Yes No
Have the products been put in quarantine? Yes No
What is the total number of temperature
recorders in the shipment?

Description and evaluation of temperature problem during transport

Continue on separate sheet if necessary.

Reporter
Name: Initials:
Job title: Address:
Company:
E-mail address: City:
Phone no: Country:
Contact person in affiliate or representative office (name and initials):

Products affected by deviation (please attach invoice and packing list)

Temperature recorder no Product name Quantity Batch no

TempTracer summary report attached Yes No If no, please fill in

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Handling, Storing, Packaging, Protecting and Delivering Novo Nordisk products 2 of 2

temperature readings

Temperature readings
Celsius Celsius hours:min
-20 to -5 : Shipment:
-5 to -3 : Storage:
-3 to 0 : Temperature recorder start date and time:
0 to +2 : / /201 ; :
(day/month/year) (hours:min) (24 hrs clock)
+2 to +8 :
+8 to +15 : Temperature recorder stop date and time:
+15 to +25 : / /201 ; :
(day/month/year) (hours:min) (24 hrs clock)
+25 to +30 :
+30 to +35 :
+35 to +40 :
Above +40 :

If a temperature reading, for example +8C, belongs to two intervals, use the lower
temperature interval, for example from +2C to +8C.

Please attach temperature recorder chart.

Filled in by (signature and date): / /201 (day/month/year)

Comments

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