Quality Assurance Person Qualification Form

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Protected when completed

Natural Health Products Directorate

Quality Assurance Person Qualification Form (complete one report per person)

Part 1

A. - Contact Information

Name Mr. Ms. Dr.

Surmame*

Given Name

Title

Language preferred: English French

Street/Suite/Land Location

City - Town

Province - State

Country

Postal/ZIP Code

Telephone No. Ext.

Fax No.

E-mail

B - Intended Quality Assurance Activities

Operations: Manufacturing Packaging Labelling Importing

Dosage Forms:
* Please refer to the annex 1 of this form for the list of dosage forms

Product Types:
* Please refer to the annex 2 of this form for the list of product types

Part 2

A - Education

Year educational program completed and duration (yyyy-yyyy)

Name of the educational institute and country

Degree diploma or certificate received (attach copies)
Indicate area of specialization (when applicable)

B - Training

Year training program completed and duration (yyyy-yyyy)

Name of the organization and country

Diploma or certificate received (attach copies)

C - Experience

Employment and duration (yyyy-yyyy)

Name of the organization and country

Roles and responsibilities

Part 3

A - Consent

I hereby consent to the collection and use of this information for the purpose of assessing my qualifications against the requirements for quality assurance persons outlined in the Good Manufacturing Practices Guidance Document. I understand that this information is protected and will not be disclosed without my consent.

Name of Quality Assurance Person (Print)

Signature

Date yyyy-mm-dd