医薬品医療機器等輸入報告確認結果情報 1 / 2 輸入報告番号 XXXXXXXXX1E 提出先 JJJJJJJJJ1JJJE 代理申請有無 JJJJJJJE 委託元利用者 XXXXE 品目の別 X JJJJJJJJJ1JJJE 事務所又は製造所 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8J JJJJJJJJ9JJJJJJJJJE 代表者 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 所在地 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8J JJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJ JJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 営業所 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJE 所在地 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8J JJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJ JJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 担当者 JJJJJJJJJ1JJJJJJJJJE 電話番号 XXXXXXXXX1E 業許可等の有無 X JJJJJJJJJ1JE 輸入の目的 JE 治験（企業）用 JE 臨床試験（医師）用 JE 試験研究・社内見本用 JE 社員訓練用 JE 展示用 JE 個人用 JE 医療従事者個人用 JE 再輸入品・返送品用 JE 自家消費用 JE その他 製造業者１ JJJJJJJJJ1JJJJJJJJJE XE JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JE ２ JJJJJJJJJ1JJJJJJJJJE XE JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JE ３ JJJJJJJJJ1JJJJJJJJJE XE JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JE ４ JJJJJJJJJ1JJJJJJJJJE XE JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JE 輸入年月日（予定日） yyyy/MM/dd 報告年月日 yyyy/MM/dd ＡＷＢ，Ｂ／Ｌ番号 XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE 取卸港 XXXXE XXXXXXXXX1XXXXXXXXXE 備考（再輸入品・返送品用） JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8J JJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJ JJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJ JJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJE 計画書 依頼者及び所在地 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 一般的名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJE 規格 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 効能または効果 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 要旨 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 実施期間 yyyy/MM/dd から yyyy/MM/dd まで 実施機関・試験研究場所・訓練場所の名称および所在地 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 診療科名 JJJJJJJJJ1JJJJJJJJJE 主任者氏名 JJJJJJJJJ1JJJJJJJJJE 交付数量 NNNNNNNE JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8J JJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJ JJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJ JJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJE 商品説明書 JE 臨床試験計画書 JE 試験研究計画書 JE 訓練計画書 JE 必要理由書 JE 通知事項 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8J JJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJ JJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJ JJJJJJ5JJJJJJJJJ6JJJJJJJJJ7JJJJJJJJJ8JJJJJJJJJ9JJJJJJJE 確認結果 JJJJJJJJJ1JJJJJJJJJE 確認年月日 yyyy/MM/dd 確認担当者 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJE 備考 CAL236-L-1 医薬品医療機器等輸入報告確認結果情報（つづき） 2 / 2 001 輸入品目名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJE 数量 NNNNNNNE JJJJJJJJJE 製造業者番号 N 化学名または本質 XE JJJJJJJJJ1JJJJJJJJJE 一般的名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJE 用途 XE JJJJJJJJJ1JJJJJJJJJ2JJJE 用途（その他） JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 効能または効果 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 規格 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 002 輸入品目名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJE 数量 NNNNNNNE JJJJJJJJJE 製造業者番号 N 化学名または本質 XE JJJJJJJJJ1JJJJJJJJJE 一般的名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJE 用途 XE JJJJJJJJJ1JJJJJJJJJ2JJJE 用途（その他） JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 効能または効果 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 規格 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 003 輸入品目名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJE 数量 NNNNNNNE JJJJJJJJJE 製造業者番号 N 化学名または本質 XE JJJJJJJJJ1JJJJJJJJJE 一般的名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJE 用途 XE JJJJJJJJJ1JJJJJJJJJ2JJJE 用途（その他） JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 効能または効果 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 規格 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 004 輸入品目名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJE 数量 NNNNNNNE JJJJJJJJJE 製造業者番号 N 化学名または本質 XE JJJJJJJJJ1JJJJJJJJJE 一般的名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJE 用途 XE JJJJJJJJJ1JJJJJJJJJ2JJJE 用途（その他） JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 効能または効果 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 規格 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 005 輸入品目名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJE 数量 NNNNNNNE JJJJJJJJJE 製造業者番号 N 化学名または本質 XE JJJJJJJJJ1JJJJJJJJJE 一般的名称 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJE 用途 XE JJJJJJJJJ1JJJJJJJJJ2JJJE 用途（その他） JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE 効能または効果 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE 規格 JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE CAL236-L-2
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