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2022 Samples Form

Vermont Office of Attorney General
109 State Street
Montpelier, VT 05609-1001

2022 Samples Disclosure Form for Manufacturers of Prescribed Products
Reporting Period for Pharmaceuticals, Biologics and Medical Devices
January 1, 2022 to December 31, 2022; Due Date: April 1, 2023

Contents (Check all that apply)

Product

Re-order Product Type Product Name Number of Samples Units/Samples Dosage Description NDC Number Weight Operations
more items

Voucher

Re-order Voucher Product Type Voucher Product Name Number of Vouchers Units/Vouchers Description NDC Number Weight Operations
more items

Other

Re-order Other Product Type Other Product Name Number of Others Other Sample Type Description NDC Number Weight Operations
more items
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