MPV Folate MBA Enrollment Section on Data Submission For

NCEH DLS Laboratory Quality Assurance Programs

Att 3g. MPVFolate Enroll&DataReturn.xlsx

MPV Folate MBA Enrollment Section on Data Submission Form (Clinical Lab)

OMB: 0920-1389

Document [xlsx]
Download: xlsx | pdf

Overview

Folate Report Form
List


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











































































































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
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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