SURVEY FORM FOR TRANSPORT & DELIVERY OF 2021 NEQAS

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SURVEY FORM FOR TRANSPORT & DELIVERY OF 2021 NEQAS - CC SAMPLES

Please check for the completion of the package. Answer the survey as completely as possible by checking and filling-up the appropriate response for each field.

NOTE: Please submit this form within 2 weeks after receiving the NEQAS Samples, so that concern may be properly addressed.

Name of Clinical Laboratory (based on your latest License to Operate) *

Complete Laboratory Address *

Region *

I. Receipt of NEQAS-CC Samples

a. Date of Receipt *

YYYY

b. Mode of Delivery *

Pick-up at NRL

by Courier Service

c. Received by *

d. Designation *

Medical Technologist

Pathologist

Administrative Officer

Clinical Laboratory Owner

Security and Maintenance Officer

Other:

II. Inspection of the Package

a. Is it properly and securely packed? *

Yes

b. Is it properly and completely labelled? *

Yes

c. Is it handled properly by the official courier/staff? *

Yes

Remarks

III. Inspection of Samples

a. Are the samples properly and completely labelled? *

Yes

b. Are the vials complete? (total of 12) *

Yes

*If incomplete, how many are present?

*If incomplete, what sample number is missing?

c. Are the vials sealed and intact? *

Yes

If not, describe the problem

(ex. Broken vial; mislabelled or tampered label)

d. Are the vials properly and completely labelled? *

Yes

IV. Others

Documents

Are you satisfied with how it is packed? *

Yes

*If not, state the reason why

Accomplished by:

Name of the Clinical Laboratory Staff *

Designation *

Medical Technologist

Pathologist

Administrative Officer

Clinical Laboratory Owner

Security and Maintenance Officer

Other:

Date Accomplished *

YYYY

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