Public Health Laboratory
Countess of Chester Health Park
Liverpool Rd,
Chester CH2 1UL
Tel 01244 366770
Fax 01244 366777
Public Health Laboratory
Royal Preston Hospital
PO Box 202, Sharoe Green Lane
Preston PR2 9HG
Tel 01772-710100
Fax 01772-713681
PUBLIC HEALTH LABORATORY SERVICE
Food and Environmental Service Laboratories
CPA Accredited
a UKAS TESTING Laboratory No 1496; Group
REQUEST FOR
MICROBIOLOGICAL EXAMINATION OF TIRAMISU (Survey No.
004010)
SENDERS REF NUMBER:
.............................................
LAB REF NUMBER:
SENDERS ADDRESS:
..............................................
DATE OF SAMPLING:
..............................................
TIME OF SAMPLING:
..............................................
SAMPLING OFFICER:
PLACE OF SAMPLING:
...........................................
...
...........................................
...
...........................................
...
SAMPLE DETAILS AND QUESTIONNAIRE
Premises Details:
1. Type of Premises:
 Italian restaurant,
 Confectioners,
 Hotel restaurant,
 Catering establishment
 Other restaurant,
 Supermarkets
other (please specify) ……………………….
2.
Premises Risk Rating (A –F): ………..
3.
Have any staff undergone any formal food hygiene training in the last three years?
Yes,
No,
Not known
Product Details:
4. Does the Tiramisu contain any of the following:
(tick all relevant boxes)
 shell eggs
cheese
 dairy cream
5. Where was the Tiramisu sampled from:
Production:
6. Was the Tiramisu made on the premises?
 pasteurised egg
 alcohol
 synthetic cream
 refrigerated display


No
Yes
egg, unknown type
 alcohol flavouring
ambient display
 Frozen display
If Yes, proceed to Question 7 and 8 only.
7. How long since the Tiramisu was produced?
8. If shell eggs are used, how are they stored?
If No, go to Question 9, 10 and 11.
9. Is the Tiramisu within its use by date?
 1 day
 ambient,
 Yes
 No
 2 days
 3 days
 refrigerated
 4days
 not known
 Not known
Delivery Details:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LABORATORY USE ONLY
Temperature on receipt:
.............................oC
R
Date received:
............................................. Time received:
..............................................
Received by:
............................................. Received from:
..............................................
.
Sample receipt:
SATISFACTORY
/ UNSATISFACTORY*
.
*Details if relevant: ………………………………………………………………………………………………….....
106734869
PROTECTING THE POPULATION FROM INFECTION
Page 1 of 2
I
Public Health Laboratory
Countess of Chester Health Park
Liverpool Rd,
Chester CH2 1UL
Tel 01244 366770
Fax 01244 366777
PUBLIC HEALTH LABORATORY SERVICE
Food and Environmental Service Laboratories
Public Health Laboratory
Royal Preston Hospital
PO Box 202, Sharoe Green Lane
Preston PR2 9HG
Tel 01772-710100
Fax 01772-713681
CPA Accredited
a UKAS TESTING Laboratory No 1496; Group
10. Who is the supplier of the
……………………………………….
11. Was the Tiramisu delivered refrigerated?
Tiramisu?
 Yes
 No
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LABORATORY USE ONLY
Temperature on receipt:
.............................oC
R
Date received:
............................................. Time received:
..............................................
Received by:
............................................. Received from:
..............................................
.
Sample receipt:
SATISFACTORY
/ UNSATISFACTORY*
.
*Details if relevant: ………………………………………………………………………………………………….....
106734869
PROTECTING THE POPULATION FROM INFECTION
Page 1 of 2
I