Required Information for Sample Submitted for Testing

/ SteriPro Labs Residual Sample Submittal Form
1500 W. Thorndale Av, Itasca, IL 60143
Phone: 630-285-9121
Fax: 630-467-0960 / 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: Same as report Address below
Company: / Company:
Address: / Address:
City/State: / City/State:
Zip/Country: / Zip/Country:
Contact Name: / Attention:
Phone No (Ext):
Fax Number: / Po Number
(required for all testing):
* Email (required):

* 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: RESIDUAL TESTING IS DESTRUCTIVE….PLEASE CALL AHEAD TO MAKE ARRANGEMENTS WITH THE LAB

REquired information for sample submitted for testing

(PLEASE Use one form per PRODUCT NAME AND FOR EACH TEST METHOD)

Product Name:
NUMBER OF samples:
PART NUMBER (if pertinent):
LOT / BATCH NUMBER (if pertinent):
SHIPPING CONDITIONS: / Dry Ice / Ice Packs / Ambient
SPECIFIY STORAGE CONDITIONS, UPON RECEIPT: / Frozen / Refrigeration / Ambient
***************IF PERTINENT TO THE TESTING, PLEASE PROVIDE THE FOLLOWING INFORMATION***************
Sterigenics Sterilization Plant:
Cycle Type: / Half Full / Times Sterilized: / 1X 2X Other:
Process Number:
Date Processed:
Protocol Number:
Consultant Name / Study Director:
SteriPro Labs Test Specification # (if applicable):
Amount Of Aeration To Which Samples Were Exposed (if applicable) – Please List Below:
Ambient / Total Time
Heated / Total Time

Other Testing:

EXOTHERMIC TESTING – ITASCA ONLY
FOR STERIPRO LAB USE ONLY
# of Samples Received: ______
Samples received on:
Dry Ice Ice Packs Ambient
Verified By/Date:______
Customer #:
WO#:
SO#:

Comments and/or Special Instructions:

Customer Signature: ______Date: _______

(REQUIRED for Testing)

Document N°: / AM-F-LB-283 / Revision N°: / 2
User must verify the revision number of printed or downloaded document against the effective version. / Confidential Information
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