TBD Cryptosporidium Laboratory Audit Application Form

Cryptosporidium Laboratory Audit Application Form
Part 1. Laboratory Information
Laboratory Name:
Address:
City:

State:

Zip:

Contact Person:
Title:
Telephone:

Fax:

Email address:
Type of laboratory (check one):
Method used in the Laboratory:

Commercial

Utility

December 2005 Method 1623

State

Academic

Other

January 2012 Method 1623.1

Number of field samples your laboratory is analyzing per month using Method 1623 and/or 1623.1:
Date of Previous Audit:

Date of Initial Approval:

Part 2. Personnel List
Name of Current Analyst and
Technicians

Current position
(Principal Analyst, Analyst, or Technician)

G-4

Evaluated during Previous Audit or
Documentation Submitted to EPA
(Yes/No)

Part 3. Method and Equipment Information: Versions of Method for which the lab is seeking evaluation
Method Procedure
Check all that apply

Key Equipment

Provide manufacturer and model for relevant pieces of equipment

Filtration
Indicate the volume filtered for each
Pall Envirochek® HV

Cubitainer
Pump

®

IDEXX Filta-Max

Flow control valve

Other (describe)

Flow meter or graduated container
Elution

Wrist action shaker

Laboratory shaker and side arms

Filta-Max® wash station

Filta-Max® Manual station

Other (describe)

Filta-Max® Automatic station
Concentration

Centrifugation
Filtration through membrane

Centrifuge - 1500 X G, swinging-bucket
centrifuge for 15 mL - 250-mL tubes

Other (describe)

Concentrator apparatus (Filta-Max only)
Purification

Dynabeads® Crypto
®

Dynabeads CG-combo

Flat-sided sample tubes
Sample mixer/rotator for 10-mL tubes
Magnetic particle concentrator for 10-mL tubes

Other (describe)
Magnetic particle concentrator for 1.5-mL tubes
Staining and Examination

Waterborne Crypt-a-GloTM

Microscope - Epifluorescence/ differential
interference contrast (HMO or DIC) microscope
with stage and ocular micrometers

Waterborne Giardi-a-GloTM

20X to 100X objectives

Waterborne AquaGloTM

Meridian Merifluor
BTF EasyStainTM

®

Manufacturer/Model

Excitation/band pass microscope filters for
fluorescein isothiocyanate (FITC) assay
(provide specifications)

G-5

Method Procedure

Key Equipment

Manufacturer/Model

Excitation/band-pass filters for 4',6-diamidino-2phenylindole (DAPI) assay

Other (describe)

(provide specifications)
Other
Descriptions of “other” method steps and other
comments:

Refrigerator for sample storage
Refrigerator for reagent storage

The above information is complete and accurate to the best of my knowledge.

Name and Signature of Laboratory Director or Designee

Date

G-6