Bimonthly Diary for October, December, February, April, June and August
Confidential when completed
If necessary, please make address label corrections in the boxes below (please print).
- Business Name
- Address (number and street)
- City
- Province / Territory
- Postal Code
Please Read Before Completing
Collected under the authority of the Statistics Act, Revised Statutes of Canada, 1985, Chapter S19. Completion of this questionnaire is a legal requirement under this Act.
Purpose of the Survey
This survey is being conducted every second month to collect the prices of prescribed drugs. The prices you report are essential to the production of the Consumer Price Index (CPI), an important indicator of how the Canadian economy is performing. This index, used by governments, businesses and private citizens, affects interest rates, taxes, wages, pensions and many other monetary transfers. Your information may also be used by Statistics Canada for other statistical and research purposes.
Confidentiality
Statistics Canada is prohibited by law from releasing any information it collects which could identify any person, business, or organization, unless consent has been given by the respondent or as permitted by the Statistics Act. Statistics Canada will use the information from this survey for statistical purposes. The Statistics Act protects the confidentiality of information collected by Statistics Canada
Record linkages
To enhance the data from this survey, Statistics Canada may combine it with information from other surveys or from administrative sources.
Inquiries
If you require assistance in completing this questionnaire or if you have any questions or comments regarding this questionnaire, please call 1-800-263-1136 or by e-mail, cpd-info-dpc@statcan.gc.ca.
A Statistics Canada representative will pick up the completed questionnaire within 48 hours.
5-4100-10: 2011-06-23
Instructions
1 Brand Name drugs
a) For each brand name drug listed below, please provide the Name, the Drug Identification Number (DIN), the total price including the dispensing fee for the quantity and strength indicated and the associated drug dispensing fee (DDF), if available.
The price provided should be on a cash payment basis (uninsured) and should be provided for the current month only.
b) For all subsequent data collection months, price the same brand name drug that was reported for the previous period.
c) If that drug is no longer available for sale, provide the information (for the same strength and quantity) for another brand name drug, within the same therapeutic class.
d) Please use the comments section on page 7 to provide reasons for changes to reported data.
STC RP# | Brand Name Drug | DIN | Strength | Quantity |
---|---|---|---|---|
Month | Brand Name Drug | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Brand Name Drug | DIN | Strength | Quantity |
---|---|---|---|---|
Month | Brand Name Drug | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Brand Name Drug | DIN | Strength | Quantity |
---|---|---|---|---|
Month | Brand Name Drug | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Brand Name Drug | DIN | Strength | Quantity |
---|---|---|---|---|
Month | Brand Name Drug | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Brand Name Drug | DIN | Strength | Quantity |
---|---|---|---|---|
Month | Brand Name Drug | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
Instructions
2 Generic drugs
a) For each active ingredient listed below, please report, based on the number of prescriptions, your best selling generic drug along with the Drug Identification Number (DIN), the total price including the dispensing fee for the quantity and strength indicated and the associated drug dispensing fee (DDF) if available.
The price should be based on a cash payment basis (uninsured) for the current month.
b) For all subsequent data collection months, price the same generic drug that was reported for the previous period.
c) If a generic drug selected in the previous period is no longer available for sale, substitute with the generic drug currently available with the same active ingredient for the same strength and quantity.
d) Please use the comments section on page 7 to provide reasons for changes to reported data.
STC RP# | Active Ingredient | Strength | Quantity |
---|---|---|---|
Month | Generic Drug Name | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Active Ingredient | Strength | Quantity |
---|---|---|---|
Month | Generic Drug Name | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Active Ingredient | Strength | Quantity |
---|---|---|---|
Month | Generic Drug Name | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Active Ingredient | Strength | Quantity |
---|---|---|---|
Month | Generic Drug Name | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Active Ingredient | Strength | Quantity |
---|---|---|---|
Month | Generic Drug Name | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Active Ingredient | Strength | Quantity |
---|---|---|---|
Month | Generic Drug Name | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
STC RP# | Active Ingredient | Strength | Quantity |
---|---|---|---|
Month | Generic Drug Name | DIN | Strength | Quantity | Price (including DDF ) | DDF |
---|---|---|---|---|---|---|
Oct. 2012 | ||||||
Dec. 2012 | ||||||
Feb. 2013 | ||||||
Apr. 2013 | ||||||
June 2013 | ||||||
Aug. 2013 |
Comments
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Month:
DIN number:
Comments :
Thank you for your cooperation
Statistics Canada use only
- RF
- UC- Specify
- OOB- Specify
- CO- Specify
- NP
- BR- Specify
- TC- Specify
- UL- Specify
- OT- Specify