Massachusetts State Public Health Lab 305 South Street
Jamaica Plain, MA 02130	Document Number/Name
FD 5.8.01 F# 1 ENVIRONMENTAL SAMPLE SUBMISSION FORM	Page 1 of 2	
			Type:
Location: Food Lab	Ver:
.12	
		Implementation Date:
11/26/14	Version Effective Date: 3/14/16	Removed from service date: m/d/yy	Issuing Authority: Microbiology Division Director	

Reason For Test:	Outbreak	Complaint	Surveillance	Routine	Salvage	Embargo (tag#)	other
Test(s) Requested:  				 Select one:	Specimen(s) will be destroyed in	days after testing is complete	Hold specimen(s) until contacted by:  			

Event Code:	Outbreak Code:	
Other Codes:		
Complaint #:	Maven ID:	
Name/address wh	ere sample was collected	
Organization Name	:	
Address:		
Date of Collection:		
Contact Person:		
Phone Number:		
Condition upon coll	ection:	
Detailed sample handling:	

Collector Information	
Organization Name:	
Address:	
	
Contact Person:	
Phone Number:	
Detailed sample handling:	Refrigerated	Frozen	On ice	Room Temperature	Other	

Relinquished By:	Print:	Sign:	Date/Time:	
Received By:	Print:	Sign:		
Comments:				

Relinquished By:	Print:	Sign:	Date/Time:	
Received By:	Print:	Sign:		
Comments:				

Relinquished
By:	Print:			Sign:	Date/Time:	
Received By:	Print:			Sign:		
Comments:						
SAMPLE LIST ON PAGE 2	

	Massachusetts State Public Health Lab 305 South Street
Jamaica Plain, MA 02130	Document Number/Name
FD 5.8.01 F# 1 ENVIRONMENTAL SAMPLE SUBMISSION FORM	Page 2 of 2	
			Type:
Location: Food Lab	Ver:
.12	
		Implementation Date:
11/26/14	Version Effective Date: 3/14/16	Removed from service date: m/d/yy	Issuing Authority: Microbiology Division Director	

 	
             Event Code:____________________                         Collection Location:________________________
		For Inspector Use Only	For Lab Use Only	
Inspector #	Sample Description
(include lot #, date code and type of container)	Sample Temperature at of collection	Lab #	Arrival Temp/ Gross Weight	

					

					

					

					

					

            If necessary add additional pages and change the page # at the top of the additional lines pages. Date an initial the 
            page # change. Ensure there the Event Code and Collection Location are at the top of each additional page. 

See Attached Narrative Form

See Attached QA 4.9.1.1 F#1 Laboratory Sample / Specimen Rejection /Concession Form