Information for Sample Submitted for Testing
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) 26209060Fax: (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: 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 / # ofSamples / 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 / SAMPLE PREPARATION (Attach Procedure) / GENERAL MICROBIOLOGYSTR-001 / External Biological Indicator Test / PRP-001 / BI Inoculation / MIC-001 / Standard Plate Count
STR-002 / Internal Biological Indicator Test / PRP-002 / Sample Item Portion (SIP) Preparation / MIC-002 / Yeast & Mold Analysis
PRODUCT STERILITY VALIDATION / BI ENUMERATION TESTING / MIC-003 / Coliform Test (Mexico ONLY)
STR-003 / Method Suitability Test (B&F Test) / ENM-001 / Population Verification / MIC-004 / Pyronema Test
PRODUCT STERILITY TESTING / ENM-002 / BI Recovery (Survivor Population) / MIC-005 / Gram Stain
STR-004 / Product Sterility Test / BIOBURDEN VALIDATION / MIC-006 / Organism ID
ENDOTOXIN(LAL) VALIDATION / BIO-008 / Exhaustive Recovery / PACKAGE TESTING
LAL-001 / Validation: Inhibition Enhancement / BIO-009 / Inoculated Recovery / PKG-001 / Burst Testing
ENDOTOXIN (LAL) TESTING / BIOBURDEN TESTING / PKG-002 / Dye Migration
LAL-002 / Routine (20.0 EU/per Device Limit) / BIO-001 / Aerobes / PKG-003 / Seal Strength / Tensile Testing
LAL-003 / Routine (2.15 EU/per Device Limit) / BIO-002 / Anaerobes / OTHER TESTING
LAL-004 / Routine (Other-Provide in Comments) / BIO-003 / Spore-formers / MIC-007 / pH Testing
ENVIRONMENTAL MONITORING / BIO-004 / Fungi / Target Range:
ENV-001 / Surface / Contact (RODAC) Plates / BIO-005 / Aerobes, Fungi / For Any Tests Not Listed - Please Use
the Comments Section to Describe and Contact the Lab for Availability
ENV-002 / Active Air Sampling-Air Strips/Plates / BIO-006 / Aerobes, Spore-formers, Fungi
ENV-003 / Passive Air Sampling-Settling Plates / BIO-007 / Aerobes, Anaerobes, Fungi, Spore-formers
SAVEBioburden Plates for Gram Stain or ID
***************IF PERTINENT TO THE TESTING, PLEASE PROVIDE THE FOLLOWING INFORMATION***************
Protocol Number: / Process Method: / Date Processed:
Cycle Type (Frac / Half / Full): / Process #: / Cycle #:
Samples for SteriPro Consulting Project / Project Name / Consultant Name
Samples for Evaluation / Test Type: / Deliver To:
FOR STERIPRO LAB USE ONLY
# of Samples Received: ______
Test Type: ______
Verified By/Date: ______
Customer#:
WO#:
SO #:
Comments and/or Special Instructions:
Customer Signature: Date: ______
(REQUIRED FOR TESTING)
Document N°: / AM-F-LB-282 / Revision N°: / 1User must verify the revision number of printed or downloaded document against the effective version. / Confidential Information
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