STANDARD PACKING LIST OBSTETRICS & PERIO THERAPY STUDY TO BE COMPLETED BY THE SHIPPING CENTER SHIPMENT NUMBER _________ PAGE ______ OF ______ DATE SHIPPED: FROM: TO: PERSON COMPLETING: DIRECTIONS: (1) Fill in the box in the upper right corner. The shipment number field should be filled in with the letter of your city and the next number in sequence. For example, Lexington’s 4th shipment would be L4. (2) Itemize the contents of the shipment. If you need more than 15 lines, use a second Standard Packing list sheet. Leave the Received field (lower right) blank. See Manual of Procedures, Sec. III.14.2. (3) Enter special instructions concerning this shipment in the Comments field. NOTE: If a shipment has more than one Standard Packing List page, the same Shipment Number is entered on all sheets. QUANTITY DESCRIPTION REC’D PLEASE RETURN POSTCARD Comments: TO BE COMPLETED BY THE RECIPIENT DATE RECEIVED: ______________________ CONDITION: __________________________ POSTCARD SENT: _____________________ PERSON: _____________________________ DCC USE ONLY: Beginning Sequence No: Ending Sequence No: OPT Form 80 V1 (1-1) Jun 03