Forensic Analytical LABORATORIES Allergen Analysis Request Form (COC) Company: Client No.: Date: Street: City: State: Zip: Contact: Phone: Fax: E-mail: Site: / Job#: Comments: Turn Around Time: DUE DATE: DUE TIME: Report Via: Fax E-Mail Verbal Please check boxes for allergen analyses requested PLEASE NOTE: 0.03g (~1 tsp) or more of dust is required in to perform the ELISA analysis 1, g 1) 2) 1) 1) 1) 1) 1) 2) 1) g g p 5 m f Bla f p g f 1) 1) qPCR 6.02 Date / Time Sample Location / Substrate b f 1, DNA Sample ID d 1) b Combo 1) Combo Der Asp Bla Can by (Bla (Bla Combo p f a Combo (Der Hev (Der & & & Alternaria Aspergillus (Mus Hev Bug 1& (Can (Fel Mite 1 1 Der 1, Mite g (Alt Mite (Asp a f d Cat 1, Dog Bed Latex Fungal Allergen f Mouse Dust Latex Cockroach (Bla Fungal: Detection Fel (Alt Cockroach Cockroach Fungal: (Der Dust Dust (Der Sampled By: Date: Time: Shipped Via: Fed Ex DHL Airborne UPS US Mail Courier Drop Off Relinquished By: Relinquished By: Relinquished By: Date / Time: Date / Time: Date / Time: Condition Acceptable? Yes No Condition Acceptable? Yes No Condition Acceptable? Yes No Received By: Received By: Received By: Date / Time: Date / Time: Date / Time: Condition Acceptable? Yes No Condition Acceptable? Yes No Condition Acceptable? Yes No Forensic Analytical Laboratories may subcontract client samples to other FALI locations to meet client requests. Office: / Telephone: (510)887-8828 * (800)827-3274 / Fax: (510)887-4218 Office: , Rancho / Telephone: (310)763-2374 * (888)813-9417 / Fax: (310)763-4450 Office: 6765 S. Eastern Avenue, , / Telephone: (702)784-0040 / Fax: (702)784-0030
Forensic Analytical LABORATORIES Allergen Analysis Request Form (COC) Company: Client No.: Date: Street: City: State: Zip: Contact: Phone: Fax: E-mail: Site: / Job#: Comments: Turn Around Time: DUE DATE: DUE TIME: Report Via: Fax E-Mail Verbal Sample ID Date / Time Sample Location / Substrate Please check boxes for allergen analyses requested PLEASE NOTE: 0.03g (~1 tsp) or more of dust is required in to perform the ELISA analysis Dust Mite (Der f 1) Dust Mite (Der p 1) Dust Mite Combo (Der f 1 & Der p 1) Cockroach (Bla g 1) Cockroach (Bla g 2) Cockroach Combo (Bla g 1& Bla g 2) Cat (Fel d 1) Dog (Can f 1) Mouse (Mus m 1) Fungal: Alternaria (Alt a 1) Fungal: Aspergillus (Asp f 1) Fungal Combo (Alt a 1 & Asp f 1) Latex Hev b 5 Latex Hev b 6.02 Bed Bug DNA Detection by qPCR Allergen Combo (Der f 1, Der p 1, Bla g 1, Fel d 1, & Can f 1) Sampled By: Date: Time: Shipped Via: Fed Ex DHL Airborne UPS US Mail Courier Drop Off Relinquished By: Date / Time: Condition Acceptable? Yes No Relinquished By: Date / Time: Condition Acceptable? Yes No Relinquished By: Date / Time: Condition Acceptable? Yes No Received By: Date / Time: Condition Acceptable? Yes No Received By: Date / Time: Condition Acceptable? Yes No Received By: Date / Time: Condition Acceptable? Yes No Forensic Analytical Laboratories may subcontract client samples to other FALI locations to meet client requests. Office: / Telephone: (510)887-8828 * (800)827-3274 / Fax: (510)887-4218 Office: , Rancho / Telephone: (310)763-2374 * (888)813-9417 / Fax: (310)763-4450 Office: 6765 S. Eastern Avenue, , / Telephone: (702)784-0040 / Fax: (702)784-0030
allgn_coc.docx