PM USA Quality System Document Page 1 Of 3 Complaint Sample Analysis Form Date Forwarded to A TS: September 17,1999 CENTRAL QA COMPLAINT UNIT (CU) Complaint ID: Complainant Name: Address: Brand: Complainant Contact Date: July 30.1999 1100497 Personal Confidential Personal Confidential Redacted Marlboro E0190 1 Cigarette Sample(s) Description: Date Sample Received in Complaint Unit: September 17,1999 Sample received in: • V a p o c Bag DWith Written Complaint • P a c k a g e Provided by Complainant X Other - Please describe: BRE w/AVF Issue (s): Alleged Physical Effect • Menthol in Non-Menthol • Possible Serious Illness/Injury Yes/NO. Alleged Taste/Odor • Other Alleged Complaints X Alleged Product Tampering • Alleged Property Damage • Please analyze to determine if blood is on the filter of the cigarette. List alleged physical effects & duration. Also, list any medications identified by compiainant: Attachments: •Complainant Correspondence •AVF X Case Log CCRB NotifiedQ Sales NotifiedQ Investigator: Johnette Coles Special Instructions: Please get maker number. to o -4 o Ol o 00 FORM: QA-QF-011-002 Revision 1 http://legacy.library.ucsf.edu/tid/hvp01h00/pdf 03/16/00 20740554 PM USA Quality System Document Page 2 Of 3 ANALYTICAL TECHNICAL SERVICES Log Book Number, Page Number: _2000 Complaint Book # 2, p. 28, C0055. Describe Sample (qty received and description of product): Marlboro (E0190) per CU, received 1 cigarette B . S a m p l e Description: (Please allow data entryfieldsto expand as needed. Copy and paste more sample tables as needed.) Cigarette Brand Packing: Factory (LVL, CAB, M/C, S/S): Maker/Packer No: Packaging Info (Code, WN#, Printer): Pack Date #####, Filter Code:: Foil Code, Carton Code (if applicable): Tax Stamp (State, Color, No.) (if applicable): UPC Code: Cigarette(s) Scanned? (yes or no) (please attach scan(s)) Visual Results (spotting, etc.): Initials: ATS/ RJJR., JSL Marlboro (E0190) per CU M/C 3C4 None None, 3C4 None None , CU/ , or Ent/ None yes Specialist stated that she had touched the sample by mistake. See attachment C. C o n t r o l S a m p l e Description: (Please allow data entryfieldsto expand as needed. Copy and paste more control sample tables as needed.) Cigarette Brand Packing: Control Information Not Applicable N> © 4*- o Oi CI o CD FORM: QA-QF-011-002 Revision 1 http://legacy.library.ucsf.edu/tid/hvp01h00/pdf 03/16/00 2074055409 PM USA Quality System Document Page 3 Of 3 D . A T S - Analytical Results! (Please allow data entryfieldsto expand as needed. Copy and paste more sample tables as needed if the information differs between samples.1) Extraction Procedure(s) (please indicate type or reference document number): Analytical Method Employed (please indicate type or reference document number): Test Results (denote differences, absences, present only in test, etc. Include CAS # where applicable.): Observed Levels Sample Results Not Applicable FT-IR Microscopy and the color test for peroxidase were run on the very small red spots on the tipping paper. The unknown red spots were identified as a mixture of cellulose and nitrocellulose. No differences were detected in sample and control. The color test for peroxidase was NEGATIVE; therefore, not blood. SPEC#3458 Not Applicable (Use individual amounts or total amounts for all compounds, please indicate type): Attach or List Uses Identified for Each Compound (where applicable): Based on the test results, the spots are too small to show a difference from the control. Also, it does not appear to be blood. Analyst Name & Date: E. ATS - Other Results Michael Griff 2-29-2000 Group Name: _^_____ Analyst Name & Date: F. PRODUCT INTEGIUTY / OCCUPATIONAL HEALTH SERVICES Analyst Name & Date: Distribution: (Please list personnel in alphabetical order.) CC: Johnette Coles - CQA CU Investigator ATS File (Jackie Love) Product Integrity File - Kathy Fox FORM: QA-QF-011-002 Revision 1 http://legacy.library.ucsf.edu/tid/hvp01h00/pdf 03/16/00 2074055410 Philip Morns USA Confidential C00055 ID#1100497 to O ^1 0^ O CJi Wfr9S0frZ0Z Doc Code: P0622 http://legacy.library.ucsf.edu/tid/hvp01h00/pdf