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Itasca, IL, USA
Ontario, CA, USA
Salt Lake City, UT, USA
Number of Test Forms
Same As Sponsor
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
(Sample ID / Lot # is the same for all Test Codes)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 2
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 3
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 4
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 5
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 6
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 7
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 8
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 9
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
Form 10
number of test forms
Sponsor Information
Billing Information
Test Code
Test Description
# Sent
# to Test
Test Individually
Test Pooled
# Per Pooled Set
CSS
Sample Id / Lot #: (To be included in final report)
Comments and Special Handling Instructions
Test Information
STAT Testing (Extra Charge)
Controlled Substance (Extra Charge)
GLP (Extra Charge)
Check One:
I
II
III
IV
V
Replacement or additional samples for an existing study:
Biohazard
SDS: Check one:
Yes, Include w/shipment
N/A
Sample Disposition
Discard Samples
Return Samples
Return Shipping Container
Pickup
Save Plates
Shipping Condition
Ambient
On Ice
On Dry Ice
Return Data Logger
Sample Storage Condition
Room Temperature
Refrigerated (2 to 8°C)
Freezer (-10 to -25°C)
Freezer (≤ -70°C)
Other
Sterilization
EO Sterilization Product
Is the Product Degassed?
Yes
No
Radiation
Cycle Type
Fractional
Half
Full
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