Fillable Test Requisition Form Toxikon (Page 2 of 2) in pdf

Test Requisition Form Toxikon Page 2

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Sample Shipment to:

Toxikon Corporation

GLP

Attn: Sample Login

15 Wiggins Avenue, Bedford, MA 01730

Ph: (781) 275-3330 FAX: (781) 271-1138

TEST REQUISITION FORM

6: LIST TEST SELECTION

TOXIKON GLP

EXTRACTIONS SPECIFICATIONS

STUDY NAME

PROTOCOL #

DIRECT

VEHICLE(S)-Select number of

CONDITION

CONTACT

extract vehicles, as applicable

* If extraction conditions are not specified, all test articles will be extracted using default conditions. Both polar (NaCl) and non-

polar (CSO) will be used as vehicles at 70°C for 24 hours for all studies other than Cytotoxicity. For Cytotoxicity, the default

conditions are 37°C for 24 hours using MEM as a vehicle.

7: EXTRACTION RATIO

3cm²/mL (Thickness ≥0.5mm)

By Surface Area:

6cm²/mL (Thickness <0.5mm)

What is total surface area per/unit?_________________________________________________________

Regulatory agencies are increasingly expecting Sponsors to be able to provide surface area information. Surface area should include all surfaces exposed to the

vehicle (Inside + Outside, both sides of slabs...). If no surface area is provided, it will be calculated following Toxikon SOP “Basic Surface Area Calculations”.

By Weight:

0.2g/mL

0.1g/mL

By Fluid Pathway:

Specify interior fluid volume______________________________________________________________

Other:

____________________________________________________________________________________

8: COMMENTS/SPECIAL INSTRUCTIONS

9: AUTHORIZATION

SPONSOR ACCEPTANCE SIGNATURE:____________________________________________

DATE:_________________________

TOXIKON USE ONLY