Form Eb Fqm-16c - Chain-Of-Custody Record For Food Samples - Missouri Department Of Health And Senior Services
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1Missouri Department of Health and Senior Services
State Public Health Laboratory
101 North Chestnut Street
Jefferson City MO 65101
573-751-3334
Chain-of-Custody Record for Food Samples
NOTE: A completed Food Test Request Form must accompany each sample.
Collector’s Name:
Collector’s Signature:
Agency Name:
Phone Number: (
)
Address:
City:
State:
Zip Code:
Sample Information:
LAB USE ONLY
Sample Description
Collection Point
Date
Time
Collector’s
Lab Number
Collected
Collected
Initials
Relinquished by: Signature & Print Name
Received by: Signature & Print Name
Date:
Time:
Relinquished by: Signature & Print Name
Received by: Signature & Print Name
Date:
Time:
Relinquished by: Signature & Print Name
Received for Laboratory by: Signature & Print Name
Date:
Time:
Relinquished by: Signature & Print Name
Received for Testing Unit by: Signature & Print Name
Date:
Time:
Disposed of by: Signature & Print Name
Sent to Central Services
Date:
Time:
(Samples to be autoclaved and placed in routine
laboratory waste)
Method of Shipment (Circle):
MSPHL Courier
Direct Delivery By: _________________
Other: _____________
EB FQM-16c Food Sample Chain-of-Custody Form
Page 1 of 1
rev 1/12/2018 AM
Attached to EB FQM-16 Food Sample Management
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