PH LC I

HOT CHT GY NGHIN

(Ban hnh km theo Thng t s: 19/2014/TT-BYT ngy 02 thng 06 nm 2014
ca B trng B Y t)
STT

TN QUC T

TN KHOA HC

ACETYLDIHYDROCODEIN

(5 , 6 )- 4,5- epoxy-3- methoxy-17

methyl- morphinan-6-yl-acetat

2.

ALFENTANIL

N-1-2-(4-ethyl-4,5- dihydro-5-oxo-1 Htetrazol-1-yl) ethyl-4- (methoxymethyl)-4piperidinyl- N- Phenylpropanamide

3.

ALPHAPRODINE

- 1,3- dimethyl-4- phenyl-4propionoxypiperidine

ANILERIDINE

1- para-aminophenethyl-4phenylpiperidine-4- carboxylic acid ethyl

ester)

5.

BEZITRAMIDE

(1-(3- cyano- 3,3- diphenylpropyl)- 4 (2oxo- 3- propionyl-1- benzimidazolinyl)piperidine)

6.

BUTORPHANOL

(-)- 17- (cyclobutylmethyl) morphinan3,14 diol

7.

CIRAMADOL

(-)-2- (- Dimethylamino-3hydroxybenzyl) Cyclohexanol

8.

COCAINE

Methyl ester ca benzoylecgonine

9.

CODEINE

(3- methylmorphine)

10.

DEXTROMORAMIDE

((+)-4 2- methyl-4- oxo-3,3- diphnyl-4 (1pyrrolidinyl)- butyl- morpholine)

11.

DEZOCIN

(-)- 13 - Amino- 5,6,7,8,9,10,11 , 12

octahydro- 5- methyl-5, 11methanobenzo- cyclodecen-3- ol

12.

DIFENOXIN

(1- (3 cyano- 3,3- Diphenylpropyl)- 4Phenylisonipecotic acid

13.

DIHYDROCODEIN

6- hydroxy- 3- methoxy-N- methyl-4,5epoxy- morphinan

14.

DIPHENOXYLATE

1-(3-cyano-3,3-diphenylpropyl)-4phenylpiperidine-4-carboxylic acid ethyl

ester

15.

DIPIPANONE

4,4- Diphenyl-6- Piperidino-3- heptanone.

1.

4.

16.

DROTEBANOL

(3,4- Dimethoxy- 17- Methyl morphinan-6

, 14 diol)

17.

ETHYL MORPHIN

3- Ethylmorphine

18.

FENTANYL

(1- Phenethyl-4-NPropionylanilinopiperidine)

19.

HYDROMORPHONE

(Dihydromorphinone)

20.

KETOBEMIDON

(4- meta- hydroxyphenyl-1- methyl-4propionylpiperidine)

21.

LEVOMETHADON

(3- Heptanone, 6- (dimethylamino)-4,4Diphenyl, (R)

22.

LEVORPHANOL

((-)- 3- hydroxy- N- methylmorphinan)

23.

MEPTAZINOL

(3(3- Ethyl-1- methylperhydroazepin-3- yl)

phenol

24.

METHADONE

(6- dimethylamino- 4,4- diphenyl-3heptanone)

25.

MORPHINE

Morphinan-3,6 diol, 7,8-didehydro- 4,5epoxy-17 methyl - (5 , 6 )

26.

MYROPHINE

MyristylBenzylmorphine

27.

NALBUPHIN

17- Cyclobutylmethyl- 7,8- dihydro- 14hydroxy- 17- normorphine

28.

NICOCODINE

Morphinan- 6- ol, 7,8- Dihydrro- 4,5epoxy- 3- methoxy- 17- methyl- 3- pyridin

mecarboxxylate (ester), ( 5, 6)

29.

NICODICODINE

6- Nicotinyldihydrocodeine

30.

NICOMORPHINE

3,6- Dinicotinylmorphine)

31.

NORCODEINE

N- Dimethylcodein

32.

OXYCODONE

(14- hydroxydihydrocodeinone)

33.

OXYMORPHONE

(14- hydroxydihydromorphinone)

34.

PETHIDINE

(1- methyl-4- phenylpiperidine-4carboxylic acid ethyl ester)

35.

PHENAZOCINE

(2- Hydroxy-5,9- Dimethyl-2- Phenethyl6,7- Benzomorphan)

36.

PHOLCODIN

(Morpholinylethylmorphine)

37.

PIRITRAMIDE

(1-(3- cyano-3,3- diphenylpropyl-4-(1piperidino)- piperidine- 4- carboxylic acid

amide)

38.

PROPIRAM

( N- ( 1- Methyl- 2 piperidinoethyl- N- 22

pyridyl Propionamide)
39.

REMIFENTANIL

1-(2-methoxy carbonylethyl)-4(phenylpropionylamino)piperidine-4carboxylic acid methyl ester

40.

SUFENTANIL

(N-4- (methoxymethyl)-1- 2- (2- thienyl)ethyl-4- piperidyl- propionanilide)

41.

THEBACON

( Acetyldihydrocodeinone)

42.

TONAZOCIN MESYLAT

(+)-1- ( 2R*,6S*,11S*)- 1,2,3,4,5,6hexahydro- 8- hydroxy- 3,6,11- trimethyl2,6- methano-3- Benzazocin- 11- yl-3-onemethanesulphonate

43.

TRAMADOL

(+)- Trans- 2- Dimethylaminomethyl-1-(3methoxy phenyl) cyclohexan-1-ol

* Danh mc ny bao gm c:
- Cc Ester v Ether ca cc cht trong bng ny nu chng khng xut
hin trong Bng khc, khi c th tn ti cc cht ester v ether .
- Mui ca cc cht ghi trong Bng ny, bao gm c mui ca ester, ether v
nhng ng phn ca cc cht trn, khi cc mui c th hnh thnh v tn ti.

PH LC II
BNG GII HN HM LNG HOT CHT GY NGHIN TRONG
THUC THNH PHM DNG PHI HP
(Ban hnh km theo Thng t s: 19/2014/TT-BYT ngy 02 thng 06nm 2014
ca B trng B Y t)

STT

TN HOT CHT THUC

GY NGHIN

HM LNG
HOT CHT TNH
THEO DNG BAZ
TRONG 1 N V
SN PHM
CHIA LIU
(Tnh theo mg)

1.

ACETYLDIHYDROCODEIN

2.

COCAINE

3.

CODEINE

100

NNG
HOT CHT
TNH THEO
DNG BAZ
TRONG SN
PHM CHA
CHIA LIU
(Tnh theo %)
2,5
0,1

100

2,5

DIFENOXIN

Khng qu 0,5 mg
Difenoxin v vi t
nht 0,025 mg Atropin
Sulfat trong 1 n v
sn phm chia liu.

5.

DIPHENOXYLATE

Khng qu 2,5 mg
Difenoxylat v vi t
nht 0,025 mg Atropin
Sulfat trong mt n v
sn phm chia liu.

6.

DIHYDROCODEIN

100

2,5

7.

ETHYL MORPHIN

100

2,5

8.

NICODICODIN

100

2,5

9.

NORCODEIN

100

2,5

10.

PHOLCODIN

100

2,5

11.

PROPIRAM

100

2,5

4.

12.

MORPHINE

13.

TRAMADOL

0,2 morphin
tnh theo
morphin base
tinh khit
37,5

PH LC III
HOT CHT HNG TM THN
(Ban hnh km theo Thng t s: 19/2014/TT-BYT ngy 02 thng 06 nm 2014
ca B trng B Y t)
TT
1.

TN QUC T

TN THNG
DNG KHC

TN KHOA HC

ALLOBARBITAL

5,5-diallylbarbituric acid

2.

ALPRAZOLAM

8- chloro -1- methy -6phenyl 4H -s- triazolo

[4,3-a] [1,4] benzodiazepine

3.

AMFEPRAMONE

4.

AMINOREX

2- amino-5- phenyl- 2oxazoline

5.

AMOBARBITAL

5-ethyl-5-isopentylbarbituric
acid

6.

BARBITAL

5,5-diethylbarbituric acid

7.

BENZFETAMINE

Diethylpropion

Benzphetamine

2-(diethylamino)
propiophenone

N-benzyl-N, dimethylphenethylamine

BROMAZEPAM

7-bromo-1,3-dihydro-5-(2pyridyl)-2H-1,4benzodiazepin-2-one

BROTIZOLAM

2- bromo-4-(ochlorophenyl)-9 methyl-6Hthieno(3,2-f)-s-triazolo( 4,3)(1,4) diazepine

10.

BUPRENORPHINE

21-cyclopropyl-7-a[(S)-1hydroxy-1,2,2trimethylpropyl]-6,14-endoethano-6,7,8,14-tetrahydro
oripavine

11.

BUTALBITAL

5-allyl-5-isobutylbarbituric
acid

12.

BUTOBARBITAL

5-butyl-5- ethylbarbituric
acid

CAMAZEPAM

7-chloro-1,3-dihydro-3hydroxy-1-methyl-5-phenyl2H-1,4-benzodiazepin-2-one
dimethylcarbamate (ester)

8.

9.

13.

14.

CHLODIAZEPOXID

15.

CATHINE

7-chloro-2-(methylamino)5-phenyl-3H-1,4benzodiazepine-4-oxide
(+)-norpseudoephedrine

(+)-(R)--[(R)-1aminoethyl]benzyl alcohol

16.

CLOBAZAM

7-chloro-1-methyl-5-phenyl1H-1,5-benzodiazepin-2,4
(3H,5H) dione

17.

CLONAZEPAM

5- (o-chlorophenyl)-1,3dihydro-7- nitro- 2H -1,4

-benzodiazepine-2 one

CLORAZEPATE

7- chloro - 2,3 - dihydro - 2 oxo -5-phenyl-1H-1,4benzodiazepine -3-carbocilic

acid

CLOTIAZEPAM

5-(o-chlorophenyl)-7-ethyl1,3 dihydro-1 methyl-2Hthieno[2,3e]-1,4 -diazepin

-2- one

CLOXAZOLAM

10-chloro-11b-(ochlorophenyl)2,3,7,11btetrahydrooxazolo-[3,2-d]
[1,4]benzodiazepin-6(5H)
one

21.

DELORAZEPAM

7-chloro-5- (ochlorophenyl)-1,3 dihydro2H-1,4 benzodiazepin-2

one

22.

DIAZEPAM

7-chloro-1,3-dihydro-1methyl-5-phenyl-2H-1,4
benzodiazepin-2 one

23.

ESTAZOLAM

8-chloro-6-phenyl-4H-striazolo[4,3-]
[1,4]benzodiazepin

24.

ETHCHLORVYNOL

1 - chloro -3- ethyl -1penten -4 - yn -3-ol

25.

ETHINAMATE

1- ethynylcyclohexanol
carbamate

26.

ETHYLLOFLAZEPATE

18.

19.

20.

ethyl -7- chloro -5- (0fluorophenyl) -2,3 - dihydro

-2 - oxo -1H-1,4
-benzodiazepine -36

carboxylate
27.

ETILAMFETAMINE

28.

FENCAMFAMIN

NN-ethyl-ethylamphetamine methylphenethylamine
N- ethyl-3- phenyl-2norbornanamine

29.

(+) 3- (methylphenethyl) amino

propionitrile

30.

FLUDIAZEPAM

7-chloro -5- (ofluorophenyl) -1,3-dihydro

-1- methyl- 2H - 1,4benzodiazepin -2- one

FLUNITRAZEPAM

5-(o-fluorophenyl) -1,3
-dihydro-1- methyl -7- nitro2H-1,4 benzodiazepin -2one

32.

FLURAZEPAM

7-chloro-1-[2(diethylamino)ethyl] -5-(ofluorophenyl)-1,3-dihydro2H-1,4-benzodiazepin -2
one

33.

GLUTETHIMID

2-ethyl-2-phenylglutarimide

HALAZEPAM

7-chloro-1,3- dihydro -5phenyl-1-(2,2,2

-trifluoroethyl)-2H-1,4benzodiazepin -2 one

HALOXAZOLAM

10-bromo-11b -(ofluorophenyl)- 2,3,7,11b

tetrahydrooxazolo [3,2-d]
[1,4] benzodiazepin -6 (5H)
one

36.

KETAZOLAM

11-chloro -8,12b - (dihydro 2,8 - dimethyl - 12b - phenyl

- 4H -[1,3] oxazino[3,2-d]
[1,4] benzodiazepin-4,7
(6H)-dione

37.

KETAMIN

(+) 2- (2-Clorophenyl)-2methylaminocyclohexanone.

38.

LEFETAMIN

39.

LOPRAZOLAM

FENPROPOREX

31.

34.

35.

SPA

(-)-N,N-dimethyl-1,2diphenylethylamine
6-(o-chlorophenyl)-2,47

dihydro-2-[(4-methyl-1piperazinyl) methylene]
-8-nitro-1H-imidazol[1,2-]
[1,4] benzodiazepin -1 one
LORAZEPAM

7-chloro-5-(ochlorophenyl)-1,3-dihydro3-hydroxy-2H-1,4
benzodiazepin -2 one

LORMETAZEPAM

7-chloro-5-(ochlorophenyl)-1,3-dihydro3-hydroxy-1-methyl-2H-1,4
benzodiazepin -2 one

MAZINDOL

5-(p-chlorophenyl)- 2,5dihydro -3H-imidazo[2,1-a]

isoindol-5-ol

43.

MEDAZEPAM

7-chloro-2,3-dihydro-1methyl-5-phenyl-1H-1,4
benzodiazepine

44.

MEFENOREX

N-(3- chloropropyl)- methylphenethylamine

45.

MEPROBAMAT

2-methyl-2-propyl - 1,3propanediol, dicarbamate

46.

MESOCARB

3- ( methylphenethyl)- N(phenylcarbamoyl) sydnone

imine

47.

METHYLPHENIDATE

Methyl -phenyl-2piperidineacetate

48.

METHYLPHENOBARBITAL

5-ethyl-1-methyl -5phenylbarbituric acid

49.

METHYPRYLON

3,3 diethyl-5- methyl-2,4

piperydine- dione

MIDAZOLAM

8- chloro- -6- (ofluorophenyl) -1-methyl-4Himidazol[1,5-a][1,4]

benzodiazepine

51.

NIMETAZEPAM

1,3 dihydro -1- methyl-7nitro-5-phenyl-2H-1,4

benzodiazepin-2-one

52.

NITRAZEPAM

40.

41.

42.

50.

1,3 dihydro -7-nitro-5phenyl-2H-1,4

8

benzodiazepin-2-one
53.

NORDAZEPAM

7-chloro- 1,3 dihydro-5phenyl-2H-1,4

benzodiazepin-2-one

54.

OXAZEPAM

7-chloro- 1,3 dihydro3hydroxy-5- phenyl-2H-1,4

benzodiazepin-2-one

OXAZOLAM

10-chloro--2,3,7,11btetrahydro-2-methyl-11bphenyloxazolo[3,2-d] [1,4]
benzodiazepin-6(5H) one

56.

PENTAZOCIN

(2R*,6R*,11R*)-1,2,3,4,5,6hexahydro-6,11-dimethyl-3(3-methyl-2-butenyl)-2,6methano-3-benzazocin-8-ol

57.

PENTOBARBITAL

5-ethyl-5-(1-methylbutyl)
barbituric acid

58.

PHENDIMETRAZIN

(+)-(2S,3S)-3,4-dimethyl-2phenylmorpholine

59.

PHENOBARBITAL

5-ethyl-5-phenylbarbituric
acid

60.

PHENTERMIN

,dimethylphenethylamine

PINAZEPAM

7-chloro-1,3-dihydro-5phenyl-1-(2-propynyl)-2H1,4-benzodiazepin-2-one

62.

PRAZEPAM

7-chloro -1(cyclopylmethyl) - 1,3 dihydro -5- phenyl -2H- 1,4benzodiazepin-2-one

63.

PYROVALERONE

4-methyl-2-(1-pyrrolidinyl)
valerophenone

64.

SECBUTABARBITAL

5-sec-butyl-5-ethylbarbituric
acid

65.

TEMAZEPAM

7- chloro - 1,3 - dihydro -3hydroxy-1 -methyl-5-phenyl

-2H- 1,4-benzodiazepin -2one

66.

TETRAZEPAM

55.

61.

7-chloro-5-(1-cyclohexen-1yl)-1,3dihydro-1-methyl2H-1,4 benzodiazepin -29

one
67.

TRIAZOLAM

8-chloro-6-(ochlorophenyl)-1-methyl-4Hs-triazolo[4,3-][1,4]
benzodiazepin

68.

VINYLBITAL

5-(1-methylbutyl)-5vinylbarbituric acid

ZOLPIDEM

N,N,6- trimethyl-2-ptolylimidazol 1,2-

pyridine-3- acetamide

69.

* Danh mc ny bao gm cc mui ca cc cht ghi trong Bng ny, khi

cc mui c th hnh thnh v tn ti.

10

PH LC IV
BNG GII HN HM LNG HOT CHT HNG TM THN
TRONG THUC THNH PHM DNG PHI HP
(Ban hnh km theo Thng t s: 19/2014/TT-BYT ngy 02 thng 06 nm
2014ca B trng B Y t)
STT

TN CHT HNG TM THN

V TIN CHT

HM LNG TI A C
TRONG MT N V
CHIA LIU

1.

ALLOBARBITAL

10mg

2.

ALPRAZOLAM

0,25mg

3.

AMOBARBITAL

10mg

4.

BARBITAL

10mg

5.

BROMAZEPAM

1mg

6.

BROTIZOLAM

0,25mg

7.

BUTOBARBITAL

10mg

8.

CAMAZEPAM

5mg

9.

CHLODIAZEPOXID

5mg

10.

CLOBAZAM

5mg

11.

CLONAZEPAM

0,5mg

12.

CLORAZEPAT

10 mg

13.

CLOTIAZEPAM

5mg

14.

DIAZEPAM

5mg

15.

ESTAZOLAM

0,5mg

16.

FLUDIAZEPAM

0,5mg

17.

FLUNITRAZEPAM

0,5mg

18.

FLURAZEPAM

5mg

19.

HALAZEPAM

5mg

20.

KETAZOLAM

5mg

21.

LOPRAZOLAM

0,25mg

22.

LORAZEPAM

0,5mg

23.

LORMETAZEPAM

0,25mg

24.

MEPROBAMAT

100mg

25.

MEDAZEPAM

5mg

26.

METHYLPHENOBARBITAL

10mg
11

27.

MIDAZOLAM

5mg

28.

NITRAZEPAM

5mg

29.

NORDRAZEPAM

30.

OXAZEPAM

10mg

31.

PARAZEPAM

5mg

32.

PENTOBARBITAL

10mg

33.

PHENOBARBITAL

25 mg

34.

SECBUTABARBITAL

10mg

35.

TEMAZEPAM

25mg

36.

TETRAZEPAM

5mg

37.

VINYLBITAL

10mg

38.

CLOXAZOLAM

1mg

39.

DELORAZEPAM

0,25mg

40.

ETHYLCLOFLAZEPAT

0,25mg

41.

NIMETAZEPAM

0,25mg

42.

OXAZOLAM

5mg

43.

PINAZEPAM

1mg

0,25mg

12

PH LC V
TIN CHT DNG LM THUC
(Ban hnh km theo Thng t s:19/2014/TT-BYT ngy 02 thng 06 nm 2014
ca B trng B Y t)
STT

TN QUC T

TN KHOA HC

1.

EPHEDRINE

([R-(R*, S*)]--[1(methylamino)ethyl]Benzenemethanol

2.

N-ETHYLEPHEDRIN

1-Ethylephedrin

N-METHYLEPHEDRIN/
3.

METHYLEPHEDRIN/
DL-METHYLEPHEDRIN

(1R, 2S)-2- (dimethylamino)-1phenyl- propanol

PSEUDOEPHEDRINE

[S-(R*, R*)]--[1(methylamino)ethyl]Benzenemethanol

ERGOMETRINE

Ergoline-8-carboxamide,9,10didehydro-N-(2-hydroxy-1methylethyl)-6-methy- [8 (s)].

6.

ERGOTAMINE

Ergotaman-3,6,18-trione,12hydroxy-2-methyl-5(phenylmethyl)-(5)

7.

N-ETHYLPSEUDOEPHEDRIN

Ethyl methyl amino phenyl

propane - 1 - ol

8.

N-METHYLPSEUDOEPHEDRIN

Dimethylamino phenyl propane

1 - ol

4.

5.

* Danh mc ny bao gm cc mui ca cc cht ghi trong Bng ny, khi

cc mui c th hnh thnh v tn ti

13

PH LC VI
BNG GII HN HM LNG TIN CHT TRONG THUC THNH
PHM DNG PHI HP
(Ban hnh km theo Thng t s: 19/2014/TT-BYT ngy 02 thng 06 nm 2014
ca B trng B Y t)

STT

TN TIN CHT

HM LNG
TI A C
TRONG MT
N V
CHIA LIU

NNG
TI A C
TRONG MT
N V
CHA CHIA
LIU

50 mg

1,5%

1.

EPHEDRINE

2.

ERGOMETRINE

0,125 mg

3.

N- ETHYLEPHEDRIN

12,5 mg

4.

N- METHYLEPHEDRIN

31,1 mg

5.

ERGOTAMINE

01 mg

6.

PSEUDOEPHEDRINE

120 mg

0,5%

14

PH LC VII
DANH SCH CC CNG TY CHU TRCH NHIM XUT KHU, NHP
KHU V CUNG NG THUC GY NGHIN, THUC HNG TM
THN, TIN CHT DNG LM THUC
(Ban hnh km theo Thng t s: 19/2014/TT-BYT ngy 02 thng 06 nm 2014
ca B trng B Y t)
STT

TN CNG TY

1.

Cng ty TNHH mt thnh vin Dc phm Trung ng 1

2.

Cng ty TNHH mt thnh vin Dc phm Trung ng 2

3.

Cng ty TNHH mt thnh vin Dc Trung ng 3

4.

Cng ty TNHH mt thnh vin Dc Si Gn

5.

Cng ty c phn Xut nhp khu y t thnh ph H Ch Minh

15

Mu s 1
Tn c s

S PHA CH THUC GY NGHIN, THUC HNG TM THN, TIN CHT DNG LM THUC
(Bt u s dng t......n......)

16

S PHA CH THUC GY NGHIN, THUC HNG TM THN, TIN CHT DNG LM THUC
Ngy
thng

S
th
t

Tn thuc nng , hm
lng

Cng thc pha

ch (cho 01 l
sn phm)

S lng thuc
thnh phm thu
c theo l
thuyt

(1)

(2)

(3)

(4)

(5)

S lng
thuc thnh
phm thu
c trn
thc t

H v tn
ngi pha
ch

H v tn
ngi
kim sot

Ghi ch

(6)

(7)

(8)

(9)

* S c nh s trang t 01 n ht, v ng du gip lai

17

Mu s 2
Tn c s
a ch:
in thoi:

S THEO DI XUT - NHP THUC GY NGHIN, THUC HNG TM THN,

TIN CHT DNG LM THUC
(Bt u s dng t....n......)

18

S THEO DI XUT - NHP THUC GY NGHIN, THUC HNG TM THN, TIN CHT DNG LM
THUC
Tn thuc, nng , hm lng,: .........................................................
n v tnh: ..........................................................................................
Ngy
thng
(1)

Ni xut, nhp

S chng
t xut,
nhp

S lng
Nhp

Xut

(2)

(3)

(4)

(5)

Cn li

S l, hn
dng

Ghi ch

(6)

(7)

(8)

* S c nh s trang t 01 n ht, v ng du gip lai

* Mi thuc phi dnh mt s trang ring, s trang nhiu hay t tu loi thuc xut, nhp nhiu hay t.
* i vi c s bn l: Ct (2): Ghi r tn, a ch bnh nhn; Ct (3): Ghi r tn, i ch ni ngi k n thuc

19

Mu s 3
Tn c s:
a ch:
PHIU XUT KHO THUC GY NGHIN, THUC HNG TM THN, TIN CHT DNG LM THUC
Xut cho c s:
a ch:
STT

Tn thuc, nng ,
hm lng

n v
tnh

S lng
xut

S l sn xut, hn
dng

Nh sn xut- tn
nc

Ghi ch

Ngi giao

Ngi nhn

Ngy.... thng.... nm....

(k, ghi r h tn)

(k, ghi r h tn)

Ngi ng u c s
hoc Ngi c u quyn

*Mu ny c th s dng :
Xut ni b c s.
Xut cho n v khc:
* Ghi r tn ngi nhn thuc, s chng minh th nhn dn
* C s c th dng ho n ti chnh thay cho mu s 7 nhng ti thiu phi c cc thng tin quy nh ti mu ny hoc
km theo Phiu bo l.
20

Mu s 4
Tn c s:

S THEO DI XUT, NHP THUC THNH PHM DNG PHI HP C CHA HOT CHT GY
NGHIN, THUC THNH PHM DNG PHI HP C CHA HNG TM THN, THUC THNH
PHM DNG PHI HP C CHA TIN CHT
Tn thuc, nng , hm lng....
n v tnh:
Nh sn xut:
Ngy
thng
(1)

Ni xut, nhp

S chng
t xut,
nhp

S lng
Nhp

Xut

Cn li

(2)

(3)

(4)

(5)

(6)

S l, hn dng

Ghi ch

(7)

(8)

* Nu lp s th s c nh s trang t 01 n ht, v ng du gip lai

21

Mu s 5
Tn c s:
S:
N NGH MUA/NHP KHU NGUYN LIU C CHA HOT CHT GY NGHIN/ NGUYN LIU
C CHA HOT CHT HNG TM THN/ NGUYN LIU C CHA TIN CHT NGHIN CU
MT HNG MI
Knh gi:
Cn c vo kh nng hot ng ca Cng ty, Cng ty.....d kin nghin cu v sn xut th mt hng thuc gy nghin,
thuc hng tm thn, tin cht dng lm thuc sau:
STT

Tn thuc
d kin

Thnh
Dng
phn, hm
bo ch
lng

S lng
Tn hot
sn xut
cht
th
GN/HTT/TC

S lng
nguyn liu d
kin nghin
cu sn xut

Tng s
lng
NL d
tr

S lng
xin
mua/nhp
khu

Ghi
ch

Cng ty ngh Cc Qun l Dc xt duyt cho cng ty mua nguyn liu c cha hot cht gy nghin/ nguyn liu c
cha hot cht hng tm thn/ nguyn liu c cha tin cht trn ti*:.. .
Cng ty cam kt s qun l v s dng nguyn liu trn theo ng qui nh ca quy ch hin hnh
Ni nhn:
- Lu ti n v

......, ngy thng

nm

Ngi ng u c s
(K tn, ng du)

* Trng hp cng ty xin nhp khu trc tip nguyn liu: gi km n hng xin nhp khu nguyn liu c cha hot cht
gy nghin/ nguyn liu c cha hot cht hng tm thn/ nguyn liu c cha tin cht theo quy nh ti Thng t hng
dn vic xut khu, nhp khu thuc v bao b tip xc trc tip vi thuc
22

Mu s 6
Tn c s:
S:
BO CO S DNG NGUYN LIU C CHA HOT CHT GY NGHIN/ NGUYN LIU C CHA
HOT CHT HNG TM THN/ NGUYN LIU C CHA TIN CHT S DNG NGHIN CU
MT HNG MI SN XUT LU HNH
Knh gi:
Din gii

S lng
nguyn liu

Tn thuc

S l

S lng thnh
phm

(1)

(2)

(3)

(4)

Ni nhn:
- Lu ti n v

S lng nguyn
liu s dng

S lng h hng

Tn

(5)

(6)

(7)

......, ngy thng

nm

Ngi ng u c s
(K tn, ng du)

23

Mu s 7
n v:
S:
S THEO DI THNG TIN CHI TIT KHCH HNG MUA THUC THNH PHM DNG PHI HP C
CHA HOT CHT GY NGHIN, THUC THNH PHM DNG PHI HP C CHA HOT CHT
HNG TM THN, THUC THNH PHM DNG PHI HP C CHA TIN CHT
(Tnh t ngy .. n ngy ..)
TT

Tn khch hng

a ch

Tn thuc

n v
tnh

S lng

Ghi ch

(1)

(2)

(3)

(4)

(5)

(6)

(7)

1.

- .........
- .........
- .........

2.

- .........
- .........
- .........

3.
Ni nhn:
- Cc QLD;
- Lu ti c s

......, ngy thng

nm

C s bo co
(K tn, ng du)
24

Mu s 8
Tn c s:
Khoa/phng :
S:
PHIU LNH THUC THNH PHM GY NGHIN, THUC THNH PHM HNG TM THN, THUC
THNH PHM TIN CHT
TT

Tn thuc, nng , hm
lng, qui cch

n v tnh

S lng
Yu cu

Thc pht

Ghi ch

Tng s:........... khon

Ngi lp bng

Ngy......thng....nm....

Ngy....thng.... nm....

Trng khoa/phng

Trng khoa dc hoc

(k, ghi r h tn)

ngi c u quyn

Ngi giao

Ngi nhn

(k, ghi r h tn)

(k, ghi r h tn)

(k, ghi r h tn)

Phiu lnh thuc thnh phm gy nghin, thuc thnh phm hng tm thn, thuc thnh phm tin cht: ti thiu phi c
02 bn chnh 01 bn lu ti Khoa Dc, 01 bn lu ti Khoa iu tr .
25

Mu s 9
Tn c s:
S:
D TR MUA THUC THNH PHM GY NGHIN, THUC THNH PHM HNG TM THN, THUC
THNH PHM TIN CHT
Knh gi:
Phn bo co k trc
TT

Tn thuc,
nng , hm
lng

n
v
tnh

S
lng
tn kho
k trc

S lng
nhp
trong k

(1)

(2)

(3)

(4)

(5)

Ni nhn:
- Lu ti c s.

Ngi lp d tr

Tng
s

Tng s
xut trong
k

(6)

(7)

Tn kho
cui k

S
lng
d tr

Duyt

Ghi ch

(8)

(9)

(10)

(11)

Ngy
......thng......nm.......

S:, Ngy ...... thng.....nm......

Duyt bn d tr ny gm....trang.....khon

Ngi ng u c s

c mua ti cng ty........

D tr ny c gi tr t ngy k ban hnh
n ht ngy 31/12/20*...
C quan duyt d tr
(k tn, ng du)
26

- D tr ny p dng cho cc c s kinh doanh, s dng thuc thnh phm gy nghin, thuc thnh phm hng tm thn,
thuc thnh phm tin cht.
- C th lm d tr b sung trong nm nhng ct 4,5,6,7,8,9 phi l nhng s liu ca thi gian trc ngy lm d tr
- D tr lm thnh 4 bn (n v d tr lu 1 bn, ni bn 1 bn, c quan duyt lu 2 bn)
* D tr ny c gi tr t ngy k ban hnh n ht ngy 31 thng 12 ca nm xin d tr mua thuc.
** i vi cc c s khm cha bnh: thc hin u thu thuc theo qui nh ca Php lut: d tr c th c lm sau
khi c kt qu u thu, gi km theo kt qu trng thu
** i vi c s KCB: khng thc hin u thu theo qui nh ca Php lut phi ghi r ngh c mua ti c s no
c quan xt duyt d tr xem xt.

27

Mu s 10
Tn c s:
S:
N HNG MUA NGUYN LIU, BN THNH PHM C CHA HOT CHT GY NGHIN/ NGUYN
LIU, BN THNH PHM C CHA HOT CHT HNG TM THN/ NGUYN LIU, BN THNH
PHM C CHA TIN CHT
Knh gi:
Phn bo co k trc
TT

Tn nguyn
liu

n
v
tnh

S
lng
tn kho
k trc

S lng
nhp
trong k

(1)

(2)

(3)

(4)

(5)

Ni nhn:
- Lu ti c s.

Tng
s

Tng s
xut trong
k

(6)

(7)

Tn kho
cui k

S
lng
d tr

Duyt

Ghi ch

(8)

(9)

(10)

(11)

Ngy ......thng......nm.......
Ngi lp d tr

Ngi ng u c s

28

Mu s 11A
Tn c s
S:....
BO CO NHP KHU THUC GY NGHIN HOC THUC HNG TM THN HOC TIN CHT
DNG LM THUC
(Bo co cho tng ln nhp khu)
Knh gi :
STT

Nguyn liu,
thuc thnh
phm nhp
khu

S giy
php
nhp
khu

Tn, a ch
nh sn xut,
tn nc

Tn, a ch
nh xut
khu, tn
nc

S lng
duyt

S lng
thc nhp

S l,
hn
dng

Ngy nhp
hng v kho

Ca khu nhp hng:

Tnh trng cht lng:

1/ t tiu chun ......... :

2/ Khng t tiu chun (nu c th tnh trng khng t):
3/ Tnh trng bao b, nhn:

Tt

Khng tt:

Ni nhn:
- Nh trn;
- Lu ta c s

Ngy thng

nm

C s nhp khu
(K tn, ng du)
29

Mu s 11B
Tn c s
S:....
BO CO XUT KHU THUC GY NGHIN HOC THUC HNG TM THN HOC TIN CHT
DNG LM THUC
(Bo co cho tng ln xut khu)
Knh gi :

STT

Nguyn liu,
thuc thnh
phm xut
khu

Ni nhn:
- Nh trn;
- Lu ta c s

S giy
php
xut
khu

Tn, a
Tn, a
S lng
ch nh sn
ch nh
S lng
thc
xut, tn nhp khu, duyt
xut
nc
tn nc

S l,
hn
dng

Ngy
xut
hng

Ngy thng

Ca khu
xut hng

nm

C s xut khu
(K tn, ng du)

30

Mu s 12A
Tn c s
S:....
Bo co nhp khu thuc thnh phm dng phi hp c cha hot cht gy nghin / thuc thnh phm dng phi
hp c cha hot cht hng tm thn/ thuc thnh phm dng phi hp c cha tin cht
Knh gi :

STT

Tn thuc,
nng , hm
lng

Ni nhn:
- Nh trn;
- Lu ta c s

n
v
tnh

Thnh
phn
chnh

Tn hot cht
Tn,
Tn, a
GN/HTT/TC
a ch
ch nh
-hm lng c
nh sn
xut
trong 1 n v
xut,
khu, tn
chia liu hoc
tn
nc
cha chia liu
nc

S
lng
cp
php

S
S
S
lng lng
lng

tn
nhp
bn
kho

Ngy thng

nm

C s nhp khu
(K tn, ng du)

31

Mu s 12B
Tn c s
S:....
Bo co xut khu thuc thnh phm dng phi hp c cha hot cht gy nghin / thuc thnh phm dng phi
hp c cha hot cht hng tm thn/ thuc thnh phm dng phi hp c cha tin cht
Knh gi :

STT

Tn thuc,
nng , hm
lng

Ni nhn:
- Nh trn;
- Lu ta c s

n
v
tnh

Thnh
phn
chnh

Tn hot cht
GN/HTT/TC -hm
lng c trong 1 n
v chia liu hoc
cha chia liu

Tn,
a ch
nh sn
xut,
tn
nc

Tn, a ch
nh nhp
khu, tn
nc

S lng
xut

Ngy thng

Tng s khi
lng hot
cht
GN/HTT/TC
tnh ra g (kg)

nm

C s xut khu
(K tn, ng du)

32

Mu s 13A
Tn c s
S:
BO CO S DNG NGUYN LIU C CHA HOT CHT GY NGHIN/ NGUYN LIU C CHA
HOT CHT HNG TM THN/ NGUYN LIU C CHA TIN CHT
Knh gi:

TT

Tn thuc,
nng ,
hm lng,
tn nguyn
liu

n
v
tnh

S lng tn
kho k trc
chuyn sang

S lng
nhp trong
k

(1)

(2)

(3)

(4)

(5)

Tng s

S lng
xut trong
k

S lng
h hao, di
d

Tn kho
cui k

Ghi ch

(6)

(7)

(8)

(9)

(10)

Ni nhn:
- Lu ta c s

Ngy thng

nm

C s bo co
(K tn, ng du)

* Tng s lng thuc ca ct 4 v ct 5 phi bng s lng ghi ct 6.

33

Mu s 13B
Tn c s
S:
BO CO S DNG NGUYN LIU C CHA HOT CHT GY NGHIN/ NGUYN LIU C CHA
HOT CHT HNG TM THN/ NGUYN LIU C CHA TIN CHT
Knh gi:
TT

Tn nguyn liu

(1)

(2)

1.

1.1

Tng s nguyn liu s

dng trong k

1.2

S lng tn kho k
trc

1.3

S lng nhp trong k

1.4

Tn kho cui k

2.

Ni nhn:

n v
tnh

(3)

Din gii

S lng
nguyn liu
s dng

Tn thuc
thnh phm

Nng , hm
lng hot cht
GN/HTT/TC

S ng k

S lng
thnh
phm

(4)

(5)

(6)

(7)

(8)

-..

-..

-..

-..

-..

-..

-..

-..

-..

-..

Ngy thng

nm
34

- Lu ta c s

C s bo co
(K tn, ng du)

* Mu ny p dng cho C s sn xut: bo co 6 thng, nm, mi ln mua/nhp nguyn liu thuc gy nghin, nguyn liu
thuc hng tm thn, tin cht dng lm thuc

35

Mu s 14
S y t tnh, thnh ph:

CNG HO X HI CH NGHA VIT NAM

c lp- T do- Hnh phc
---------------

S:

Ngy

thng

nm

BO CO CNG TC QUN L THUC GY NGHIN HOC THUC

HNG TM THN HOC TIN CHT DNG LM THUC
Nm:.......
Knh gi: Cc Qun l Dc - B Y t
I. Qun l thuc gy nghin, hng tm thn (tin cht) trn a bn:
1. S c s bn bun thuc gy nghin, hng tm thn (tin cht):
2. S c s bn l thuc thnh phm gy nghin, hng tm thn (tin cht):
3. S c s y t s dng thuc thnh phm gy nghin, hng tm thn (tin cht):
3.1. S c s trong ngnh y t s dng thuc thnh phm gy nghin, hng tm thn
(tin cht):
3.2. S c s ngoi ngnh y t s dng thuc thnh phm gy nghin, hng tm thn
(tin cht):
4. Cng tc qun l, s dng:
II. S dng, tn kho thuc thnh phm gy nghin, hng tm thn (tin cht)

STT

Tn thuc,
nng , hm
lng, dng
bo ch

Quy
cch
ng gi

n
v
tnh

S
lng
tn
kho
nm
trc

S
lng
nhp

S
lng
s
dng

S
lng
tn
kho

* S lng s dng: L s lng bn l ca c s bn l v s lng s dng trong cc

c s y t trn a bn.
* S lng tn kho: l s lng tn kho ti cc c s bn bun, c s bn l, c s y t
trn a bn ti thi im bo co.
Gim c S Y t
(K tn, ng du)

36