Laboratory
Name:
Laboratory
ID:

*
Lab
Sample
ID:
Sample
collection
time:

*
PWS
ID:
*
Sample
collection
date:

*
Facility
ID:
Turbidity
(
NTU):

*
Sample
Collection
Point
ID:

*
Initial
precision
and
recovery
(
IPR)
Method
blank
Field
(
monitoring)
sample
Ongoing
precision
and
recovery
(
OPR)
Matrix
spike
(
MS)
Proficiency
testing
(
PT)

*
Estimated
number
spiked:
Crypto
Giardia
Spiking
time:

*
Sample
volume
spiked
(
L):
Spiking
date:

Spiking
suspension
ID:
Spiking
analyst:

Filter
type
(
circle
one):
Envirochek
Envirochek
HV
Filta­
Max
CrypTest
Other
(
specify)

Did
filter
clog
(
circle
one):
Yes
No
Filter
lot
number:

*
Number
of
filter(
s)
used?:
Filtration
time:

*
Volume
filtered
(
mL):
Filtration
date:

Elution
procedure
(
circle
one):
Wrist
shaker
Filta­
Max
wash
station
Stomacher
Backflush/
sonication
Elution
buffer:
Elution
time:

Elution
buffer
lot
number:
Elution
date:

Elution
buffer
expiration
date:
Elution
analyst:

Procedure
(
circle
one):
Centrifugation
Filta­
Max
concentrator
Other
(
specify)

*
Pellet
volume
after
concentration
(
mL):
Concentration
analyst:

*
Total
volume
of
resuspended
concentrate
(
mL):
IMS
analyst:

*
Volume
of
resuspended
concentrate
transferred
to
IMS
(
mL):
Slide
prepartion
time:

Number
of
subsamples
processed
through
entire
method:
Slide
preparation
date:

IMS
lot
number:
Slide
preperation
analyst:

IMS
system
(
circle
one):
Dynal
GC­
Combo
Dynal
anti­
Crypto
Other
(
specify)

Slides
(
circle
one):
Meridian
Dynal
Waterborne
Other
(
specify)

Detection
kit
(
circle
one):
Merifluor
Crypt­
a­
glo
Giardi­
a­
glo
Aqua­
glo
Other
(
specify)

Staining
time:

Detection
kit
lot
number:
Staining
date:

Staining
analyst:

Comments:

*
=
data
entered
into
LT2
Data
Collection
System
Concentration,
IMS,
and
Slide
Preparation
Slide
Staining
(
must
be
completed
within
72
hours
of
application
of
sample
to
the
slide)
Sample
Spiking
Information
(
for
IPR,
OPR,
MS,
and
PT
samples
only)
Method
1622/
1623
Bench
Sheet
Sample
Identification
Information
Sample
Filtration
Sample
Elution
(
must
be
performed
within
96
hours
of
sample
collection/
filtration)
Sample
type
(
circle
one):

(
must
be
completed
on
same
working
day
that
samples
are
eluted)

June
2003
