IDENTIFICATION FUND SOURCE:

NUMBER
DEEM TOOL PROJECT
0 3 5 0 SAMPLE REPORTING FORM 1234 Pharma_
(match with DV)
CHECK IDENTIFICATION VOUCHER IDENTIFICATION

C1 CHECK NUMBER 0013691 V1 DISBURSEMENT

VOUCHER NUMBER 002
C2 CHECK DATE 11/05/2008
(MM/DD/YYYY) V2 DISBURSEMENT
VOUCHER DATE 11/05/2008
(MM/DD/YYYY)

CHECK DATA OTHER VOUCHER DATA

C3 PAYMENT DATE 11/05/2008 V3 DISBURSEMENT VOUCHER PARTICU-

(MM/DD/YYYY) LARS:

C4 GROSS AMOUNT _D1,500,000 1000 BOXES (box of 100s) of 500mg

Acetamenophen (Panadol) capsules
C5 TAX _na
________________________________________________
C6 PENALTY none ________________________________________________

C7 PRICE DIFFEREN- none V4 TYPE OF PROCURE-

TIAL MENT Exclusive Distributorship_

C8 CHECK AMOUNT D1,500,000 V5 COMPLETE SIGNATURES? (Encircle

choice.)
C9 NAME OF PAYEE: 1 Yes 2 No X

Die Young Pharmaceutical Company V5N If No, fill up the following table for missing sig-
______________________________________________ natures:

C10 ADDRESS OF PAYEE: CERTIFICATION NAME POSITION

(1) (2) (3)
Persian Tower, DC St. Mortalia Polarus
C Heddy Honcho Medical Chief
______________________________________________

COUNT OF FORMS REMARKS/OBSERVATIONS

VOUCHER ACTUAL
FORMS COUNT COUNT - Stated Exclusive Certificate
(1) (2) as support document in DV,
but is not attached
F1 PURCHASE RE- 1 1 - Panadol is brand name for
QUESTS acetamenophen therefore
indeed only one distributor,
F2 PURCHASE OR- 1 1 but a lot of brand offerings
DERS for acetamenophen
medicine in market as
1 1 validated by DEEM team
F3 INVOICES - Attached advertisement
shows attempt of hospital
F4 INSPECTION RE- na na to procure medicine
PORTS through competitive
F5 INSPECTION AND bidding but resorted to
ACCEPTANCE RE- 1 1 exclusive distributorship
PORTS - BAC resolution is not
conclusive or justified that
F6 ABSTRACTS OF na na exclusive distributorship
CANVASS method of procurement
should be utilized
F7 ABSTRACTS OF 1 1 - Medical Chief, Dr. Honcho
BIDS did not sign DV
- Supplier delivered 250mg
F8 EXCLUSIVITY 1 1 instead of 500mg of
CERTIFICATE Panadol, End user accepted
IDENTIFICATION COUNT OF LINE
NUMBER
DEEM TOOL PROJECT ITEMS:

0 3 5 0 ITEM INFORMATION 1 of 1
_________________

DESCRIPTION OF LINE ITEMS

LINE ITEM
NUMBER LINE ITEM DESCRIPTION

1 1000 boxes (of 100s) of Panadol capsules 500mg (P.O. Reference Number 4322)

10

11

12
 LINE ITEM
IDENTIFICATION DEEM TOOL PROJECT NUMBER
NUMBER
PURCHASE REQUEST __1 OF
0 3 5 0 INFORMATION __1 ITEMS

REQUEST IDENTIFICATION DETAILS ON REQUESTED ITEM

R1 PURCHASE RE- R10 DESCRIPTION OF REQUESTED ITEM:

QUEST NUMBER 1235
1000 boxes (box of 100s) of Panadol
R2 PURCHASE RE- capsules 500mg_
QUEST DATE 07/01/2008
(MM/DD/YYYY) _______________________________________________

_______________________________________________
DETAILS ON REQUEST SOURCE
R11 QUANTITY 1000 boxes of 100s
R3 REQUESTING DE-
PARTMENT Pharma Dept. R12 UNIT 100 per box

R4 REQUESTING SEC- R13 ESTIMATED UNIT

TION Pharma Dept. COST D1,500 per box_

R5 NAME OF REQUES- R14 ESTIMATED COST D1,500,000.00

TING PERSON Harley Syrup
R15 PURPOSE: Replenish stocks
R6 POSITION OF RE-
QUESTING PERSON
Head Pharmacist

R7 DATE OF REQUEST 07/01/2008

(MM/DD/YYYY)

OTHER REQUEST DATA REMARKS/OBSERVATIONS

R8 COMPLETE SIGNATURES? (Encircle - Purchase Request seems to be in order

choice.)

1 Yes X 2 No

R9 FOR RECURRING ITEM, WITH AC-

COMPANYING STOCK POSITION RE-
PORT? (Encircle choice.)
1 Yes 2 No 3 NA X
 LINE ITEM
IDENTIFICATION DEEM TOOL PROJECT NUMBER
NUMBER
PURCHASE ORDER __1_ OF
0 3 5 0 INFORMATION _1__ ITEMS

ORDER IDENTIFICATION DETAILS ON ORDERED ITEM

O1 PURCHASE ORDER O6 MODE OF PROCURE-

NUMBER 4322 MENT Exclusive Distributorship

O2 PURCHASE ORDER O6E If exclusive, is there an attached certificate for

exclusive distributorship? (Encircle choice.)
DATE 09/12/2008
(MM/DD/YYYY) 1 Yes 2 No X

SUPPLY DATA O7 SAME ITEM DESCRIPTION AS IN PUR-

CHASE REQUEST? (Encircle choice.)
1 Yes X 2 No
S1 SAME SUPPLIER/DEALER AS IN DIS-
BURSEMENT VOUCHER? (Encircle O7N If No, write the item description in Purchase
choice.)
Order:
1 Yes X 2 No
________________________________________________
S1N If No, write the name of supplier/dealer in ________________________________________________
Purchase Order:
________________________________________________
______________________________________________
O8 SAME PURCHASE REQUEST NUMBER
S2 PLACE OF DELIVERY State Hospital_ CITED? (Encircle choice.)

S3 DELIVERY TERM Full del. n/30 1 Yes X 2 No

S4 PENALTY CLAUSE O8N If No, write the Purchase Request Number and
date cited in the Purchase Order:
SIGNATORY Jane Smith

S5 POSITION OF SIGNA- PURCHASE REQUEST NUMBER DATE

(1) (2)
TORY Director Sales

S6 DATE IN PENALTY
CLAUSE 09/18/2008 O9 QUANTITY _________________
(MM/DD/YYYY)
O10 UNIT _________________

O11 UNIT COST _________________

O12 AMOUNT _________________

OTHER ORDER INFORMATION REMARKS/OBSERVATIONS

O3 INSPECTION NOTE: - No Certificate of Exclusivity is

attached.
IAR noted complete delivery
- Acetamenophen is the generic name
O4 DATE OF INSPEC- of Panadol – there are a lot of
TION NOTE _10/26/2008 manufacturers and distributors for
(MM/DD/YYYY) acetamenophen in the market.
O5 COMPLETE SIGNATURES? (Encircle
Therefore, no need for Exclusive
choice.) Distributorship method of
1 Yes X 2 No
procurement. Instead, this should be
procured through public competitive
O5N If No, fill up the following table for missing bidding.
signatures:
- 250mg of Panadol delivered and
CERTIFICATION NAME POSITION accepted but requisitioned for
(1) (2) (3) 500mg capsules in PR
 LINE ITEM
IDENTIFICATION NUMBER
NUMBER
DEEM TOOL PROJECT __1_ OF
0 3 5 0 INVOICE INFORMATION _1 _ ITEMS

INVOICE IDENTIFICATION DETAILS ON INVOICED ITEM

D1 INVOICE NUMBER 1091 D8 SAME ITEM DESCRIPTION AS IN PUR-

CHASE ORDER? (Encircle choice.)
D2 INVOICE DATE 10/26/2008_ 1 Yes X 2 No
(MM/DD/YYYY)
D8N If No, write the item description in Invoice:
OTHER INVOICE DATA ________________________________________________

________________________________________________
D3 PAYMENT TERM 45 days after
acceptance of full delivery ________________________________________________

D4 SAME SUPPLIER/DEALER AS IN DIS- D9 QUANTITY ________________

BURSEMENT VOUCHER? (Encircle
choice.) D10 UNIT ________________

1 Yes X 2 No D11 UNIT COST ________________

D4N If No, write the name of supplier/dealer in

Invoice: D12 AMOUNT ________________

______________________________________________ D13 EXPIRY DATE OF ITEM ____/____/_______

(MM/DD/YYYY)
D5 WITH CUSTOMER’S SIGNATURE?
(Encircle choice.)
REMARKS/OBSERVATIONS
1 Yes X 2 No
- no stamp of Internal Audit Unit
D5Y If Yes, write the name of signatory and date:
- All other info is consistent with
Invoice. However, it is noted that
SIGNATORY DATE 250mg was delivered and accepted
(1) (2) by end user but the Invoice bills for
500mg of Panadol
Alberto Redentor 10/26/2008

D6 WITH STAMP OF PROPERTY SEC-

TION? (Encircle choice.)
1 Yes X 2 No

D6Y If Yes, write the date of stamp:

10/26/2008_

D7 WITH STAMP OF INTERNAL AUDIT?

(Encircle choice.)

1 Yes 2 No X

D7Y If Yes, write the date of stamp:

____/____/_______
 LINE ITEM
IDENTIFICATION DEEM TOOL PROJECT NUMBER
NUMBER
INSPECTION AND _1 _ OF
0 3 5 0 ACCEPTANCE INFORMATION _1 ITEMS

GENERAL ACCEPTANCE DATA DETAILS ON ITEM ACCEPTED

A1 SAME SUPPLIER/DEALER AS IN DIS- A9 IS THE ITEM DESCRIBED AS “SAME

BURSEMENT VOUCHER? (Encircle AS SPECIFIED IN PURCHASE ORDER?”
choice.) (Encircle choice.)

1 Yes X 2 No 1 Yes 2 No X

A1N If No, write the name of supplier/dealer in In- If Yes, skip to A11.
spection and Acceptance Report:
A10 SAME ITEM DESCRIPTION AS IN PUR-
___________________________________________
CHASE ORDER? (Encircle choice.)
A2 SAME PURCHASE ORDER NUMBER 1 Yes 2 No X
AND DATE? (Encircle choice.)
A10N If No, write the item description in Inspection
1 Yes X 2 No and Acceptance Report:

A2N If No, write the purchase order number and Delivered 250mg Panadol capsules instead
date in Inspection and Acceptance Report: of 500 mg capsules
PURCHASE ORDER DATE ________________________________________________
NUMBER (2)
(1) ________________________________________________

A11 UNIT 1000 boxes of 100s

A3 SAME INVOICE NUMBER AND DATE? A12 SAME QUANTITY AS IN PURCHASE
(Encircle choice.) ORDER? (Encircle choice.)
1 Yes X 2 No
1 Yes X 2 No

A3N If No, write the invoice number and date in

A12N If No, write the quantity in Inspection and Ac-
Inspection and Acceptance Report:
ceptance Report:

INVOICE NUMBER DATE ________________________________________________

(1) (2)
A13 SAME UNIT COST AS IN PURCHASE
ORDER? (Encircle choice.)

A4 REQUISITIONER Heddy Honcho_ 1 Yes X 2 No

A5 DATE ITEM WAS RE- A13N If No, write the unit cost in Inspection and Ac-
ceptance Report:
CEIVED AT PROPERTY
SECTION 10/26/2008_ ________________________________________________

A6 WITH SIGNATURE OF PROPERTY A14 AMOUNT D1,500,000_

OFFICER? (Encircle choice.)
1 Yes X 2 No
REMARKS/OBSERVATIONS
- Delivered 250 mg of Panadol
A7 NATURE OF ACCEPTANCE (Encircle capsules instead of 500 mg capsules
choice.) as stated in Purchase Request &
1 Complete X 2 Partial
Purchase Order
- Supplier did not give Certificate of
A8 WITH STAMP OF INSPECTION AND Exclusivity and yet was considered
ACCEPTANCE? (Encircle choice.) accepted delivery
- Batch testing certificate and MRA
1 Yes X 2 No Certificate of Product Registration
was provided by supplier
A8Y If Yes, write the name of signatory and date
of stamp:

SIGNATORY DATE
(1) (2)
Alberto Redentor 10/26/2008