MPV Folate MBA Enrollment Section on Data Submission For

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Overview

Folate Report Form
List

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Sheet 1: Folate Report Form

		CDC Method Performance Verification Program							Form Approved OMB No. 0920-xxxx Exp. Date xx/xx/20xx
		Folate Microbiologic Assay Method Comparison
Instructions
·	Enter information only in the yellow shaded cells; cell will become green when populated
·	Run these samples in the same way as you would routine patient samples
·	Run the samples designated for each day in duplicate over a period of 4 days
·	Record all results with three significant figures (i.e., 105, 10.5, 1.05, 0.105)
·	E-mail this completed worksheet to: [email protected]
·	Retain the vials in your freezer in case of any questions regarding the ID or results
Laboratory Details:			Laboratory ID#
			Name of Laboratory/Country
Shipment Details:			Shipment received date
			Was the shipper received cold?
			Did shipper contain a temperature monitor?
			Color of dot on temperature monitor
Assay Details:	Matrix
	Analyte	Folate
	Units
	Assay	Microbiologic Assay
	Instrument					(Manufacturer/Model)
(if a kit used)	Kit Details					(Name/Manufacturer)
Calibrator(s)
Calibration Range:
	Low Cal		0
	High Cal		0
	LOD		0
Run	Assay Date	Sample	Sample ID	Result 1	Result 2	Notes
				0	0
Day 1		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		QC1
		QC2
Day 2		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		QC1
		QC2
Day 3		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		QC1
		QC2
Day 4		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		QC1
		QC2
Laboratory Notes

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Sheet 2: List

Chromatographic/LC-MS/MS [should not include MeFox]

Chromatographic/HPLC-UV

Immunoassay/Protein Binding Assay

Microbiologic Assay

Other (Please Describe Below)

5-MethylTHF

Folic Acid

Do not know

Other (Please Describe Below)

Serum

Whole Blood

AGP

CRP

Ferritin

Folate

sTfR

Vitamin A

Vitamin B12

Vitamin D

nmol/L

µmol/L

ng/mL

µg/dL

pg/mL

mg/L

Yes

No

No Color

Pink/Red