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Health Canada Sant QUALIFIED INVESTIGATOR UNDERTAKING Natural Health Products Directorate An undertaking must be completed by the qualified investigator responsible for the conduct of the clinical trial at the site specified below. The completed undertaking must be retained by the clinical trial sponsor for a period of 25 years. Part 1 Clinical Trial Protocol Information Please check one of the following Clinical Trial Application CTA Protocol Title Protocol if known Part 2 Natural Health Product NHP / Sponsor Information A. NHP Information Brand Name / Product Code Medicinal Ingredient s See Clinical Trial Application and Attestation Form Submission Number if known B. Sponsor of Clinical Trial Name of Sponsor Full Name No Abbreviations Street / Suite / PO Box City / Town Province / State Country Postal / ZIP Code C. Contact for this Clinical Trial Contact Name E-mail Company Name Full Name No Abbreviations Telephone No* Fax No* Part 3 Qualified Investigator Information Name of Site Full Name No Abbreviations Province Title Language Preferred English French B. Qualified Investigator Name In respect of the identified clinical trial I certify as the qualified investigator for this site that 1. I am a physician or dentist and a member in good standing of a professional medical or dental association as defined in Part 4 of the Natural Health Products Regulations 2. I will supervise the medical care and medical decisions respecting this clinical trial at this site 3. I will conduct this clinical trial in accordance with Good Clinical Practices and 4. I will immediately on discontinuance of the clinical trial by the sponsor in its entirety or at a clinical trial site inform both the clinical trial subjects and the Research Ethics Board for this site of the discontinuance provide them with the reasons for the discontinuance and advise them in writing of any potential risks to the health of clinical trial subjects or other persons. The completed undertaking must be retained by the clinical trial sponsor for a period of 25 years. Part 1 Clinical Trial Protocol Information Please check one of the following Clinical Trial Application CTA Protocol Title Protocol if known Part 2 Natural Health Product NHP / Sponsor Information A. NHP Information Brand Name / Product Code Medicinal Ingredient s See Clinical Trial Application and Attestation Form Submission Number if known B. NHP Information Brand Name / Product Code Medicinal Ingredient s See Clinical Trial Application and Attestation Form Submission Number if known B. Sponsor of Clinical Trial Name of Sponsor Full Name No Abbreviations Street / Suite / PO Box City / Town Province / State Country Postal / ZIP Code C. Sponsor of Clinical Trial Name of Sponsor Full Name No Abbreviations Street / Suite / PO Box City / Town Province / State Country Postal / ZIP Code C. Contact for this Clinical Trial Contact Name E-mail Company Name Full Name No Abbreviations Telephone No* Fax No* Part 3 Qualified Investigator Information Name of Site Full Name No Abbreviations Province Title Language Preferred English French B.

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