C-105

Protocol and Report Documentation Requirements

Section C — Record Management Revision 5 12 pages

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1.0 Purpose 
 
 This procedure establishes the requirements for the issuance and tracking of cGMP protocols
 and reports at Ion Labs, Inc. 
 
 2.0 Scope 
 
 This procedure applies to all protocols and reports generated at Ion Labs, Inc. unless the
 
 protocol or report is not a cGMP document, or if the protocol or report is covered by a more
 
 specific procedure. 
 
 3.0 Responsibility 
 
 3.1 All persons writing, reviewing and approving a protocol or report are responsible for
 assuring content is consistent with the requirements established in this procedure and
 
 that it is complete and thorough. 
 
 3.2 All protocol reviewers and approvers are responsible for ensuring that the content
 
 applicable to their particular area of expertise or discipline is appropriate with regard to
 
 approach, methods, procedures, and analysis. Reviewers/approvers must conduct
 reviews in a timely manner and provide appropriate feedback and comments.
 
 3.3. Quality is responsible for ensuring that document content is consistent with this
 procedure as part of the review and approval of the document. 
 
 4.0 Definitions 
 
 4.1 DC — Document Control 
 
 4.2 BPR — Batch Production Record 
 
 
 

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 4.3 IQ — Installation Qualification; a formal assessment of the means of accommodating
 
 new equipment and testing its materials 
 
 Example: IQ should ensure that necessary utilities, space. etc. are available for the
 
 equipment, and that the equipment is made of the materials specified.
 
 4.4 OQ — Operational Qualification; a formal challenge of equipment parameters
 
 Example: If equipment must operate in specific ranges, those should be verified.
 
 4.5 PQ — Performance Qualification; similar to OQ but tested under load
 
 Example: If equipment must operate in specific ranges, those ranges are measured
 
 while in use with materials. 
 
 4.6 Validation — The formal documentation of demonstrating that a method, system, or
 
 process will consistently operate within pre-described parameters and are suitable for
 the intended use 
 
 4.7 Verification — The formal demonstration that a validated method, system, or process is
 suitable for a specific application that may vary slightly from the parameters used for
 
 validation (e.g. a different but similar product). Verification activities are usually a sub-
 
 set of the activities carried out for validation 
 
 4.8 SOP — Standard Operating Procedure 
 
 4.9 DC — Document Control 
 
 4.10 cGMP — Current Good Manufacturing Practices 
 
 4.11 CQS — Core Quality System 
 
 5.0 References 
 
 5.1 C-105-F1, Form, Protocol and Report Initiation Request 
 
 a2 C-105-F2, Form, Protocol and Report Closure Request 
 
 

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 Protocol and Report Documentation Requirements 
 
 533 C-201, SOP, Deviation and Investigation Procedure 
 
 5.4 QS-112, SOP, Core Quality Systems and Quality Events 
 
 5.5 QS-112-F1, Form, Quality Event Extension Request 
 
 5.6 QS-112-F2, Form, Quality Event Cancellation Request 
 
 5.7 QS-112-F3, Form, Quality Event Amendment Request 
 
 6.0 Procedure 
 
 6.1 Protocols 
 
 6.1.1 Protocols define processes, execution steps, expected outcomes, limits,
 
 acceptance criteria, etc. for cGMP activities not otherwise defined by SOPs,
 Batch Records, Test Methods, Specifications, etc. Protocols may be used for
 
 non-cGMP activities in accordance with this procedure at the discretion of
 
 Quality Management. 
 
 Typical activities requiring the use of a protocol include but are not limited to
6.1.2 the following:

 6.1.2.1. Validation / Verification of a cGMP process, system, or method
 
 6.1.2.2 Reprocessing of products or materials 
 
 6.1.2.3 IQ/OQ/PQ of equipment, instrumentation, systems, software, etc.
 
 6.1.2.4 See also Section 6.3.4 to assign protocol numbers to documents
 authored by individuals and organizations outside of Ion Labs.
 
 6.1.3 Protocol Record Management 
 
 6.1.3.1 Original pre-approved protocols are maintained by DC.
 
 6.1.3.2 If required for execution, DC will issue a controlled copy of the pre-
 
 approved protocol. 
 
 

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 Protocol and Report Documentation Requirements 
 6.1.3.3 Controlled copies used for execution will be returned to DC upon
 
 completion and will be maintained with the original pre-approved
 
 protocol, or with the BPR if necessary. 
 
 6.1.3.4 Documentation/data generated and/or collected during the execution of
 
 a protocol must be filed with the protocol and/or subsequent report(s).
 Typically it is attached to the protocol report(s). 
 
 e Reprocessing protocols and all documentation generated during its
 
 execution will be maintained in the BPR, with the completed
 protocol document. 
 
 6.2 Reports 
 
 6.2.1 Reports summarize information and document conclusions and decisions
 
 impacting cGMP activities not otherwise defined by SOPs, Batch Records, Test
 Methods, Specifications, etc. Reports may be used for non-cGMP activities in
 
 accordance with this SOP at the discretion of Quality Management.
 
 6.2.2 Typical activities requiring the use of a report include but are not limited to the
 
 following: 
 
 6.2.2.1 Summary of the execution of a protocol governed by this SOP.
 
 6.2.2.2 Reports of and responses to audits / inspections by customers, third
 
 party auditors, and government agencies. 
 
 6.2.2.3 See also Section 6.3.4 to assign report numbers to documents authored
 
 by individuals and organizations outside of Ion Labs. 
 
 6.2.3. All conclusions made in reports must be based on objective review of the data
 
 and observations made during the execution of the protocol. 
 
 6.2.4 Final reports must explain any deviations from associated protocols or other pre-
 
 established and approved criteria that occurred and the impact these deviations
 have on the integrity of the study. 
 
 

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 6.2.4.1 When deviations from acceptance criteria or approved specifications
 
 are observed, these must be investigated to the degree necessary to
 
 understand why the deviation occurred and the impact of that
 deviation. 
 
 6.2.4.2 A report may use SOP C-201 Deviation and Investigation Procedure
 and the associated forms to document a deviation, and then reference
 
 the deviation number in the report. 
 
 6.2.4.3 A report may document a deviation in the body of the report instead of
 
 using SOP C-201 Deviation and Investigation Procedure and the
 
 associated forms as long as the same principles established in C-201
 Deviation and Investigation Procedure are applied. 
 
 6.2.5 Report Record Management 
 
 6.2.5.1 Original approved reports are maintained by DC. 
 
 6.2.5.2 Documentation/data generated and/or collected during the execution of
 a protocol must be filed with the protocol and/or subsequent report(s).
 
 Typically it is attached to the protocol report(s). 
 
 6.3. Requirements Common to Protocols and Reports 
 
 6.3.1 Document Format 
 
 6.3.1.1 The format of a protocol and/or report will vary based on the type of
 
 study being conducted or reported, its complexity, and objectives. DC
 
 may have templates available from previously executed protocols or
 reports. 
 
 6.3.1.2 Some protocols are written with space provided to document the
 execution of the protocol (i.e. blanks to fill in). If the document is
 
 intended to serve as both a protocol and a report, only a protocol
 number will be assigned. See section 6.4 for assignment of numbers.
 
 

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 Protocol and Report Documentation Requirements 
 
 Documents that serve this dual purpose (protocol and report) must
 
 have the following features: 
 
 Pre-Approval Signatures 
 
 Post-Approval Signatures 
 
 A mechanism to document deviations from the protocol.
 
 A place to reference additional documentation as applicable.
 
 6.3.2 Content 
 
 6.3.2.1 Protocols and reports have similar content sections. There are a few
 
 content sections listed here that only apply to one or the other which is
 
 explained in the list below. 
 
 6.3.2.2 Protocol / Report Number and Pagination 
 
 The protocol / report number assigned to the document should be
 on the front page of the document. Include this number on the
 
 header or footer of each page along with pagination of pages.
 Attachments do not need to be paginated, and the protocol / report
 
 number does not need to be on each page of the attachments. See
 Section 6.3.3 for additional requirements for attachments.
 
 6.3.2.3 Introduction / Scope / Purpose 
 
 One or more of these sections should be used as applicable. In
 general it is important to explain why the protocol / report exists.
 
 Cross-references to events or circumstances that created the need
 for the document should be provided. Specifically if a deviation,
 
 investigation, etc. is the reason for the document, then reference the
 specific event number. If the document pertains to a specific
 
 system or piece of equipment then the system or equipment should
 be specified including applicable identification numbers.
 
 

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 6.3.2.4 Rationale 
 
 If applicable, provide explanation and / or justification for the
 
 approach taken or for the conclusions drawn. 
 
 6.3;25 Procedure 
 
 The procedure defines what must be done (in a protocol) or what
 was done (in a report). It must be detailed enough for the reader to
 
 achieve or repeat the intended purpose. The procedure section may
 . reference other documents (i.e. batch records, SOPs, previous
 
 protocols, etc.) rather than repeat information unnecessarily.
 
 6.3.2.6 Acceptance Criteria 
 
 The Acceptance Criteria section defines what limits that must be
 
 achieved if a protocol is considered successful. If a report is used
 to summarize a protocol, then the acceptance criteria should be
 
 included or referenced in the report. Acceptance criteria may not
 be necessary in a report depending upon the nature of the report.
 
 6.3.2.7 List of Attachments 
 
 e Any documents necessary to support the protocol or report must be
 
 listed within the document so that a reader will be able to discern
 
 whether or not all required attachments are present. It is best to
 include this section with an entry of “none” if there are no
 
 attachments needed to support the document. 
 
 6.3.2.8 Signatures 
 
 At least two signatures are required for each protocol or report. At
 least one signature must be from the author of the report. At least
 
 one signature must be from the Quality department. If multiple
 departments are significantly involved in the execution of the
 
 

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 protocol and /or are impacted by the results in a report, then at least
 
 one signature from each of these departments should be present.
 
 Note: Additional signature requirements listed in section 6.3.1.2
 above. 
 
 6.3.3. Attachments 
 
 6.3.3.1 Must be properly identified with a reference to the specific protocol
 
 and/or report number to which they are related. 
 
 6.3.3.2 Must be listed within the protocol and/or report as a list of attachments.
 
 Note: Reprocessing protocols do not require this information to be
 added to normal BPR pages used to document reprocessing activities.
 
 Only supplemental pages for reprocessing will have this information
 
 added and listed in the protocol as an attachment. 
 
 6.3.4 Protocols / Reports authored outside of Ion Labs 
 
 6.3.4.1. If a protocol or report is authored by a 3" party service provider,
 
 auditor, customer, or government agency, those reports are not likely
 
 to meet requirements defined by this SOP. 
 
 6.3.4.2 Ion labs personnel may write an internal protocol or report to provide
 
 the necessary content and supply the outside report as an attachment to
 the document written internally. The internal document may be
 
 minimal and reference the attachment for the majority of the content.
 
 6.4 Protocol or Report Initiation / Closure 
 
 6.4.1 Initiate a protocol or report by submitting form C-105-F1 Protocol and Report
 Initiation Request to DC. 
 
 6.4.2. Close a protocol or report by submitting form C-105-F2 Protocol and Report
 Closure Request to DC. 
 
 

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 6.5 Additional Requirements from QS-112 Core Quality Systems and Quality Events
 
 6.5.1 This procedure is considered a CQS that is also controlled by SOP QS-112 Core
 
 Quality Systems and Quality Events. 
 
 6.5.2 The term “event” is a generic reference to any of the CQS covered by SOP QS-
 
 112 Core Quality Systems and Quality Events. The term “event” is used
 
 interchangeably with specific CQS events as applicable (i.e. either “protocol” or
 “report” here). 
 
 6.5.3 SOP QS-112 Core Quality Systems and Quality Events provides instructions
 common to all Ion Labs CQS including the following topics which are not to be
 
 duplicated here: 
 
 e Assignment of unique event numbers (i.e. Protocol and Report numbers)
 
 e Logging of events DC 
 
 e Assignment of event due dates 
 
 e Event due date extensions 
 
 e Event cancellations 
 
 e Event revisions / amendments 
 
 e Monitoring of open events 
 
 e Record management and retention instructions 
 
 

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 Protocol and Report Documentation Requirements 
 
 7.0 Revision History 

| Rev | Date | Description of Changes | CCR # | By |
|-----|----------|------------------------|-------|----|
| 0 | 05/07/10 | New procedure. ~ - Made general reorganization to provide clarification, changed SOP title, expanded protocol type and protocol number, made protocol aN number assignment and all issuing and maintenance activities the 12-0145 V. Iltcheva responsibility of DC | - | - |
| 2 | 10/03/14 | Scheduled review: updated SOP format. Scheduled review: removed paper log. Added requirements for | 14-0777 | V. Iltcheva |
| 3 | 01/07/19 | electronic log. Added new categories for protocol numbers. : , Removed obsolete information. Corrected formatting. Changed ee ee BUS SOP number. Added reference to C-501. | - | - |
| 4 | 01/16/20 | Added reference to QS-112. Added protocol due date. Removed protocol numbering system. Updated logo, formatting, and title. Clarified documentation ; 06/03/22 requirements for reprocessing protocols. Updated throughout for CC-22-0254 K. Burris uniformity to other procedures. | 19-0602 | K. Burris |

 

[SOP 

 ION LABS Protocol and Report Initiation Request 
 
 Form: C-105-F1 CCR No. CC-22-0254 Revision: l 
 
 EVENT INFORMATION 
 
 Protocol / Report 
 Revision # 
 Number 
 
 Protocol / Report 
 
 Title / Description 
 
 EVENT TYPE 
 | O PRTCL- Protocol | C1 RPT- Report 
 
 EVENT DATES 
 Protocol / Report Protocol / Report 
 Open Date Due Date 
 
 PROTOCOL / REPORT — OWNER (LE. ASSIGNED TO) 
 
 COMMENTS 
 
 Name Title Signature Date 
 Completed By: 
 (Author) 
 Assignment Accepted By: 
 ] N/A if same as completed by 
 Approved By: 
 (Quality) 
 
 
 

[SOP 

 ION LABS Form: C-105-F2 ProtocoClC aRnNdo R.e porCtC C-l2o2s-u0r2e5 R4e quest Revision: 1
 
 EVENT INFORMATION 
 
 Protocol / Report 
 Revision # 
 Number 
 
 Protocol / Report 
 Title / Description 
 
 DATE INFORMATION 
 Closed Date | 
 
 CLOSURE SUMMARY 
 Include as applicable: Evidence and/or statement of closure, cross references to supporting documentation,
 general conclusions / outcome, etc. 
 
 Name Title Signature Date 
 Completed By: 
 (Author) 
 Approved By: 
 (Quality)