ElectronicDataSubmissionForm dilutions

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ElectronicDataSubmissionForm dilutions Powered By Docstoc
					                                                           DATA SUBMISSION FORM
                                                                          DILUTIONS
                              Used to submit data when dilutions are performed on VALIDATE® products.
Instrument Sys/Model#:                                                                                             Testing date:
Instrument ID/SN/Name:
    Institution Name:                                                                                         How would you like your report returned to you?
    Mailing Address:                                                                                             Please select only one method of return.

             Attention:                                                                                         [ ] electronic copy via e-mail
                                Please list the person to be contacted regarding                             (please provide your e-mail address below)
                                    any issues with this data submission                                E-mail:
     Contact Name:                                                                                              [ ] hardcopy via US Mail
  Phone #                                         Fax #
                          ®
Indicate the VALIDATE product being submitted: please use a separate form for each product and each instrument system.
Product: ________                   Set:                     Kit Lot #:                                                  Kit Exp:
Record the method ID for the analyte(s) assayed in the space(s) provided.
Enter the duplicate or triplicate recovered values for each analyte.
                                                                    the VALIDATE® Level in the 'Level'
To report results from Levels run without dilution: Record the VALIDATE® Level in the ‘Level’ column. column.
Enter the duplicate or triplicate recovered values for each analyte.
To report results from diluted Levels: Indicate a diluted value with an asterix (*) in the 'Level' column.
Enter the duplicate or triplicate recovered values from the prepared dilutions.
Record the materials used to prepare dilutions and '# Parts' in corresponding columns.
An example is provided on the bottom of this form.
FOR ADDITIONAL ASSISTANCE IN COMPLETING THIS FORM, PLEASE VISIT www.mainestandards.com OR CALL OUR
TECHNICAL SUPPORT DEPARTMENT AT 1-800-377-9684

Method ID:                     Units:                         Dilution Material #1                    Dilution Material #2
   Level         Rep 1         Rep 2         Rep 3         Material            Parts               Material            Parts




Method ID:                     Units:                         Dilution Material #1                    Dilution Material #2
   Level         Rep 1         Rep 2         Rep 3         Material            Parts               Material            Parts




EXAMPLE DILUTION SUBMISSION:
Method ID: ALB_01              Units:      g/dL               Dilution Material #1                    Dilution Material #2
   Level     Rep 1             Rep 2          Rep 3        Material            Parts               Material            Parts
     0         0                 0              0
     1         1                 1              1
     2         3                 3              3
     3         5                 5              5
     *         6                 6              6           Level 3             1 Part              Level 4            1 Part
     4         7                 7              7
     5         9                 9              9

This form is available at www.mainestandards.com and may be printed for use or completed electronically.
Completed forms may be emailed, faxed or mailed to Maine Standards Company.

Email: datareduction@mainestandards.com                                   Fax: 207-892-2266
Mail To: 765 Roosevelt Trail Windham, ME 04062                            ATTN: Data Reduction Department




       41275ea7-27fc-46cf-8ec5-4f7bd2081150.xls

				
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