Specimen Collection Log
| Form ID |
FRM-BIO-001 |
Revision |
1.0 |
Collection Session Information
| Field |
Entry |
| Collection Date |
|
| Collector Name |
|
| Collector ID |
|
| Collection Site/Location |
|
| Protocol/Study ID |
|
| Batch Number |
|
Specimen Collection Record
Specimen 1
| Field |
Entry |
| Specimen ID (Barcode) |
|
| Subject/Donor ID |
|
| Consent Verified? |
☐ Yes |
| Verification Method |
☐ Wristband ☐ Verbal ☐ Photo ID ☐ Other: _______ |
| Specimen Type |
☐ Blood ☐ Tissue ☐ Urine ☐ CSF ☐ Other: _______ |
| Collection Container |
|
| Collection Time |
: (24hr) |
| Volume/Quantity |
|
| Collection Site (anatomical) |
|
| Ischemia Time (if tissue) |
Warm: ___ min Cold: ___ min |
| Specimen Appearance |
☐ Normal ☐ Hemolyzed ☐ Lipemic ☐ Icteric ☐ Other: _______ |
| Notes/Deviations |
|
Specimen 2
| Field |
Entry |
| Specimen ID (Barcode) |
|
| Subject/Donor ID |
|
| Consent Verified? |
☐ Yes |
| Verification Method |
☐ Wristband ☐ Verbal ☐ Photo ID ☐ Other: _______ |
| Specimen Type |
☐ Blood ☐ Tissue ☐ Urine ☐ CSF ☐ Other: _______ |
| Collection Container |
|
| Collection Time |
: (24hr) |
| Volume/Quantity |
|
| Collection Site (anatomical) |
|
| Ischemia Time (if tissue) |
Warm: ___ min Cold: ___ min |
| Specimen Appearance |
☐ Normal ☐ Hemolyzed ☐ Lipemic ☐ Icteric ☐ Other: _______ |
| Notes/Deviations |
|
Specimen 3
| Field |
Entry |
| Specimen ID (Barcode) |
|
| Subject/Donor ID |
|
| Consent Verified? |
☐ Yes |
| Verification Method |
☐ Wristband ☐ Verbal ☐ Photo ID ☐ Other: _______ |
| Specimen Type |
☐ Blood ☐ Tissue ☐ Urine ☐ CSF ☐ Other: _______ |
| Collection Container |
|
| Collection Time |
: (24hr) |
| Volume/Quantity |
|
| Collection Site (anatomical) |
|
| Ischemia Time (if tissue) |
Warm: ___ min Cold: ___ min |
| Specimen Appearance |
☐ Normal ☐ Hemolyzed ☐ Lipemic ☐ Icteric ☐ Other: _______ |
| Notes/Deviations |
|
Specimen 4
| Field |
Entry |
| Specimen ID (Barcode) |
|
| Subject/Donor ID |
|
| Consent Verified? |
☐ Yes |
| Verification Method |
☐ Wristband ☐ Verbal ☐ Photo ID ☐ Other: _______ |
| Specimen Type |
☐ Blood ☐ Tissue ☐ Urine ☐ CSF ☐ Other: _______ |
| Collection Container |
|
| Collection Time |
: (24hr) |
| Volume/Quantity |
|
| Collection Site (anatomical) |
|
| Ischemia Time (if tissue) |
Warm: ___ min Cold: ___ min |
| Specimen Appearance |
☐ Normal ☐ Hemolyzed ☐ Lipemic ☐ Icteric ☐ Other: _______ |
| Notes/Deviations |
|
Processing Summary
| Field |
Entry |
| Total Specimens Collected |
|
| Specimens with Deviations |
|
| Processing Start Time |
: (24hr) |
| Processing End Time |
: (24hr) |
| Processed By |
|
Aliquot Summary (if applicable)
| Specimen ID |
# Aliquots |
Volume Each |
Storage Location |
Temp |
|
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|
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|
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Transfer Information
| Field |
Entry |
| Transferred To |
|
| Transfer Time |
: (24hr) |
| Transport Condition |
☐ Ambient ☐ 4°C ☐ Frozen ☐ LN2 |
| Received By |
|
| Receipt Time |
: (24hr) |
| Condition on Receipt |
☐ Acceptable ☐ Compromised (describe below) |
Notes on condition:
Verification
| Field |
Entry |
| All specimens labeled correctly? |
☐ Yes |
| All documentation complete? |
☐ Yes |
| Any deviations reported? |
☐ Yes ☐ No ☐ N/A |
| Deviation Report # (if applicable) |
|
Collector Signature
| Field |
Entry |
| Signature |
|
| Date |
|
| Time |
|
Supervisor Review (if deviations noted)
| Field |
Entry |
| Reviewed By |
|
| Date |
|
| Comments |
|
Form FRM-BIO-001 Rev 1.0 - Specimen Collection Log
