Office of Drug, Device and Cosmetic

Department or School Letterhead

Date

Office of Drug, Device and Cosmetic

Registration and Compliance

Pennsylvania Department of Health

132 Kline Plaza, Suite A

Harrisburg, PA 17104

Dear Madam/Sir:

I am a scientific investigator employed by the University of Pittsburgh-Of the Commonwealth System of Higher Education. In accordance with the Pennsylvania Controlled Substances, Drug, Device and Cosmetic Act, I am hereby requesting an exemption from registration for the receipt, possession and utilization of prescription (i.e., legend) drugs and/or controlled substances and/or prescription devices in the course of my laboratory research and/or teaching activities. Specified below is my affiliation with the University of Pittsburgh; the nature of my laboratory research and/or teaching activities; the specific prescription drugs and/or controlled substances and/or prescription devices used in these activities; and the specific University laboratory location(s) where these materials will be received, stored and used under my direction.

University of Pittsburgh Affiliation:

Specify your name, degree (e.g., Ph.D., M.S.), academic appointment (e.g., Professor, Associate Professor, Assistant Professor, Instructor), department and school affiliation

Summary of Research and/or Teaching Activities:

Summarize the general nature of your laboratory research and/or teaching activities wherein you will be utilizing the prescription drugs and/or controlled substances and/or prescription devices.

Specific Prescription Drugs, Controlled Substances, and/or Prescription Devices for which an Exemption from Registration is Requested:

List all of the prescription (i.e., legend) drugs, controlled substances, and/or prescription devices being used, or planned for use, in your laboratory research and/or teaching programs.

Laboratory Location(s) Wherein the Prescription Drugs and/or Controlled Substances and/or Prescription Devices will be Stored and/or Used:

List all laboratory locations (building, room #) wherein prescription (i.e., legend) drugs and/or controlled substances and/or prescription devices will be stored and/or used under your direction.

Please accept my sincere thanks, in advance, for your consideration of, and prompt response to, this request for registration exemption. I understand that any changes to this initial request should be forwarded to your attention in a timely manner.

Respectfully,

______

Signature of Scientific Investigator

Inserted printed name and academic title (i.e., Dean or Department Chair) of scientific investigator’s responsible academic administrator

______

*Signature of Scientific Investigator’s

Dean or Department Chair

*Note to PA DOH: University of Pittsburgh policies require the signature of the scientific investigator’s responsible dean or department chair as validation of the scientific investigator’s authority to possess and use the requested prescription drugs and/or controlled substances and/or prescription devices.