SteriPro Labs Microbiology Sample Submittal Form
1500 W. Thorndale Av, Itasca, IL 60143
Phone: 630-285-9121 Fax:630-467-0960
687 S. Wanamaker Av, Ontario, CA 91761
Phone: 909-390-2120 Fax: 909-390-1592
James Watt No. 22 Parque Industrial Cuamatla
Cuautitlan Izcalli, Estado de Mexico 54730
Phone: (0115255) 26209060 Fax: (0115255) 58703246
SEND REPORT TO:
SEND INVOICE TO:
Company:
Address:
City/State:
Zip/Country:
Contact Name:
Phone No (Ext):
Fax Number:
* Email (required):
Company:
Address:
City/State:
Zip/Country:
Attention:
Same as report
Address below
PO NUMBER
(REQUIRED FOR ALL TESTING):
* NOTE: All Test Reports will be scanned via email. If Hard Copies are desired ($10 charge will apply), please specify:
FAX
MAIL
TURN TIME:
STANDARD
EXPEDITE – ADDITIONAL FEE (CALL LAB FOR TIMELINE AND PRICING)
PRODUCT HAZARDS:
NONE
YES - ATTACH APPROPRIATE MSDS (REQUIRED FOR ALL LIQUIDS AND POWDERS)
RETURN SAMPLES:
NO
YES – Provide FedEx/UPS # for Shipping:
**NOTE: MOST TESTING IS DESTRUCTIVE…PLEASE CALL AHEAD TO MAKE ARRANGEMENTS WITH THE LAB
(CALL FOR SAMPLE CLEANING QUOTE)
INFORMATION FOR SAMPLE SUBMITTED FOR TESTING
(PLEASE USE ONE FORM PER TEST CODE AND SAMPLE DESCRIPTION)
TEST CODE
SAMPLE DESCRIPTION
# of SAMPLES
PART #
LOT/BATCH #
SteriPro Labs Test Specification # (if applicable)
Specify storage conditions, upon receipt (REQUIRED):
Ambient
Refrigeration
Frozen
TEST CODES FOR LABORATORY SERVICES
BI STERILITY
STR-001 External Biological Indicator Test
STR-002 Internal Biological Indicator Test
PRODUCT STERILITY VALIDATION
Method Suitability Test (B&F Test)
STR-003
PRODUCT STERILITY TESTING
Product Sterility Test
STR-004
ENDOTOXIN (LAL) VALIDATION
Validation: Inhibition & Enhancement
LAL-001
ENDOTOXIN (LAL) TESTING
Routine (20.0 EU/per Device Limit)
LAL-002
Routine (2.15 EU/per Device Limit)
LAL-003
Routine (Other-Provide in Comments)
LAL-004
ENVIRONMENTAL MONITORING
ENV-001 Surface / Contact (RODAC) Plates
ENV-002 Active Air Sampling-Air Strips/Plates
ENV-003 Passive Air Sampling-Settling Plates
SAMPLE PREPARATION (Attach Procedure)
BI Inoculation
PRP-001
Sample Item Portion (SIP) Preparation
PRP-002
BI ENUMERATION TESTING
Population Verification
ENM-001
BI Recovery (Survivor Population)
ENM-002
BIOBURDEN VALIDATION
Exhaustive Recovery
BIO-008
Inoculated Recovery
BIO-009
BIOBURDEN TESTING
Aerobes
BIO-001
Anaerobes
BIO-002
Spore-formers
BIO-003
Fungi
BIO-004
Aerobes, Fungi
BIO-005
Aerobes, Spore-formers, Fungi
BIO-006
BIO-007 Aerobes, Anaerobes, Fungi, Spore-formers
SAVE Bioburden Plates for Gram Stain or ID
GENERAL MICROBIOLOGY
Standard Plate Count
MIC-001
Yeast & Mold Analysis
MIC-002
MIC-003
Coliform Test (Mexico ONLY)
MIC-004
Pyronema Test
Gram Stain
MIC-005
Organism ID
MIC-006
PACKAGE TESTING
PKG-001 Burst Testing
PKG-002 Dye Migration
PKG-003 Seal Strength / Tensile Testing
OTHER TESTING
pH Testing
MIC-007
Target Range:
For Any Tests Not Listed - Please Use
the Comments Section to Describe and
Contact the Lab for Availability
***************IF PERTINENT TO THE TESTING, PLEASE PROVIDE THE FOLLOWING INFORMATION***************
Protocol Number:
Cycle Type (Frac / Half / Full):
Samples for SteriPro Consulting Project
Samples for Evaluation
Process Method:
Process #:
Project Name
Test Type:
Date Processed:
Cycle #:
Consultant Name
Deliver To:
FOR STERIPRO LAB USE ONLY
Comments and/or Special Instructions:
# of Samples Received: _____________
Test Type: ________________________
Verified By/Date: ___________________
Customer #:
Customer Signature:
Date: _______________
(REQUIRED FOR TESTING)
Document N°:
AM-F-LB-282
User must verify the revision number of printed or downloaded document against the effective version.
WO #:
SO #:
Revision N°:
2
Confidential Information
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