Industrial Chemicals Worksheet
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1FLAG:
ORIGINAL
CHECK
ADDITIONAL
1. Product
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
3. Seals
2. Sample Number
Intact
INDUSTRIAL CHEMICALS WORKSHEET
None
Broken
State of Sample
4. Date Rec’d (mm/dd/yyyy)
5. Received From
6. District or Laboratory
Frozen
Room Temp
Refrigerated
7. Description of Sample
8. Net Contents
9. Labels
Not Applicable
Not Determined
Original(s) Submitted
Copies Submitted
None Submitted
None Accompanying Sample
Other (Specify):
10. Summary of Analysis
a. Method (Select applicable method(s))
Pesticide Analytical Manual (PAM):
302E8
302E9
Laboratory Information Bulletin (LIB)
Other Method
Modifications to Method
(Explain below)
4110 Luke Fatty Sep/pak
4399 FEDSO
4304 MSD/SIM Detection Method
4464 LC/MS/MS
for Halogen Compounds
Detection Method
4308 MSD/SIM Detection Method
QuEChERS: J.AOAC 86
for NSO Compounds
412-431 (2003)
b. Sample Preparation and Composite (Describe)
Rec’d Prepared
c. Results
Quantitation (PPM)
Confirmation
Detector:
XSD
FPD
GC/MSD
LC/MS/MS GC/MS/MS
Residues (Enter below)
(Briefly describe below)
Mode:
P
SIM
MRM
MRM
d. Additional Information
11. Reserve Sample (Enter relevant post-analysis information)
13. Worksheet Check
12 a. Analyst Signature (Broke seal)
c.
a. By
b.
d.
b. Date (mm/dd/yyyy)
14. Date of Report (mm/dd/yyyy):
FORM FDA 431e (9/11)
Attach.
Page 1 of
EF
PSC Publishing Services (301) 443-6740
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