Chain Of Custody Form
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9000 Commerce Parkway, Suite B
Mount Laurel, NJ 08054
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Phone: 877-428-4285/856-231-9449
Fax: 856-231-9818
Chain of Custody
–Mold / Fungal Analysis –
Contact Information
Client Company: ____________________________
Project Number: __________________________
Office Address:
____________________________
Project Name: __________________________
City, State, Zip: ____________________________
Primary Contact: __________________________
Fax Number:
____________________________
Office Phone: __________________________
Email Address:
____________________________
Cell Phone: __________________________
Mold Analytical Services/ Special Instructions
Non-Culturable:
Mold /Bioaersol Fungal Spore Trap:
Proprietary Method for Airborne Fungal Spore Identification/Quantitation Zefon Air-O-Cell
, or Air-O-Cell-like cassette
TM
(ex. Allergenco
, Micro5
, etc.)
TM
TM
Mold/Tape, Swab, Bulk:
Proprietary Method for Direct Transfer Fungal Spore Identification Zefon Bio-Tape
, other transparent cellophane tape
TM
Mold/Miscellaneous:
Proprietary Method for Fungal Spore Identification in Carpets, Dusts, Surfaces Micro-Vacuum Cassettes, Carpet
samples, etc. (ex. AIHA Vol. 64, No. 6, 11/2003)
Culturable:
Mold/Bioaersol Fungal Contact Plate (Qualitative Only):
Proprietary Method for Airborne Fungal Spore Identification (non-quantifiable) Anderson
Plates, Bio-Cassette
TM
TM
Surface Air Sampler, or aersol impacted growth medium
Mold/Bioaersol Fungal Contact Plate (Qualitative and Quantifiable):
Proprietary Method for Airborne Fungal Spore Identification (Quantifiable in CFU) Anderson
Plates, Bio-
TM
Cassette
, or aersol impacted growth medium
TM
Mold/Swab, Bulk:
Proprietary Method for Growth and Identification of Fungal Spores Sealable/Sterile Swab, Bulk, (Call lab for
availability)
Mold/Miscellaneous:
Proprietary Method for Growth and ID of Fungal Spores in Carpets, Dusts, Surfaces Micro-Vacuum Cassettes, Carpet
samples, etc. (ex. AIHA Vol. 64, No. 6, 11/2003)
Turnaround Time
Preliminary Results Requested Date: _________________________
Verbal
Email
Fax
Specific date / time
10 Day
5 Day
3 Day
2 Day
1 Day*
12 Hour**
6 Hour**
RUSH**
Note:
Viable/Culturable samples may require several days in order to establish countable colony forming units (CFU) of fungi.
* End of next business day unless otherwise specified. ** Matrix Dependent. ***Please notify the lab before shipping.***
Chain of Custody
Relinquished (Name/Organization): __________________________
Date: ________________
Time: ___________________
Received (Name / iATL):
__________________________
Date: ________________
Time: ___________________
Sample Login (Name / iATL):
__________________________
Date: ________________
Time: ___________________
Analysis(Name(s) / iATL):
__________________________
Date: ________________
Time: ___________________
QA/QC Review (Name / iATL):
__________________________
Date: ________________
Time: ___________________
Archived / Released: ____________QA/QC InterLAB Use: ______________ Date: ________________
Time: ___________________
Celebrating 25 years…one sample at a time
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