Sample Data Sheet

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Sample Data Sheet

Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer;
1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Sample Data Sheet

Use this form to keep track of environmental samples taken for Legionella culture during a legionellosis outbreak investigation.
NOTE: this is NOT a chain of custody form.

Sample ID

Date Collected

Specimen Type
(e.g., water,
swab, filter)

Sample Data Sheet | www.cdc.gov/legionella/outbreak-toolkit/
07/2015

CS254961-A

Sample Description (e.g., room 253 shower)

Temp
(ºF)

Free Cl2
(ppm)

Total Cl2
(ppm)

pH