Annex 7:
Price components data collection form
Name of data collector:
Region:
Sector:
Name/code of dispensing outlet:
Product name, dosage, strength:
Manufacturer:
Pack size:
Product type:
Production:
 originator brand
 imported
Type of data:
field
 generic
 locally produced
hypothetical
Any additional information about target medicine:
Type of charge
Stage 1
Manufacturers selling
price
Insurance and freight
CIF
Charge
basis
price
Price to
which charge
is applied
Amount
of charge
Comments
Type of
charge
Charge
status
Charge
basis
Price to
which charge
is applied
Amount
of charge
Comments
Type of charge
Charge
status
Charge
basis
Price to which
charge is
applied
Amount
of charge
Comments
Procure price
value
Type of charge
Charge
status
Charge
basis
Price to which
charge is
applied
Amount
of charge
Comments
Charge
basis
Price to which
charge is
applied
Amount
of charge
Comments
Stage 2:
Landed
price
Source:
Stage 3:
Wholesaler
or medical
store
Source:
Stage 4:
Retailer or
dispensary
Procure price
Type of charge
Stage 5:
Dispensed
price
Selling price
value
Charge
status
value
Example:
Type of
charge
Stage 2:
Landed
price
Charge
status
Inspection
V
Port
charges
Importer's
mark-up
Pharmacy
board
NF
Charge
basis
Fee
V
%
V
%
Price to which
charge is
applied
MSP +IF
Cumulative
sub-total
Cumulative
Sub-total
Amount
of charge
$200
3%
1%
Comments
Minimum charge on
all shipments less
than $5000