10,120-1d Proficiency Testing PT

OMB Control Number: 0583-0082
Expiration Number:
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0082. The time required to complete this information collection is
estimated to average 5 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.
U.S. Department of Agriculture
Food Safety and Inspection Service
Accredited ;Laboratory Program

PROFICIENCY TESTING (PT)
SAMPLE RESULTS
1. ALP Lab Number:

2. PT Sample Number:

3. Date Sent: (mm/dd/yyyy)

4. Due Date for Results: (mm/dd/yyyy)

INSTRUCTIONS: FSIS: Complete items 1 through 6.
Laboratory: Report analytical findings under item 7. See the
Instruction page for additional instructions.

5. Laboratory Address:

Email Results by the Due Date to: [email protected]
6. Sample Type or Name:
Food Chemistry

7. Results Entry Report to Two Decimal Places:

Amount

Analyte
Moisture

Unit
%

Protein

%

Fat

%

Salt

%

Ash (Optional)

%

Submitted by Signature:

Printed Name:

FSIS 10,120-1d (09/08/2023)

Title:

REPLACES FSIS 10,120-1 (02/02/2017) WHICH IS OBSOLETE

Date: (dd/mm/yyyy)

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Instructions for Handling PT Samples and Reporting Results
This is a laboratory sample;not for consumption

Keep sample refrigerated or frozen. Freeze the sample for storage.
Laboratories must report all analytes for interlaboratory PT sample results, unless officially excused from doing so.
Treat the sample in the same manner as any routine sample except as noted by the FSIS Accredited Laboratory Program (ALP).
Laboratories may not subcontract out any PT samples. If a laboratory is unable to analyze samples, ALP personnel should be
notified.
No comments should be made on the PT Sample Results Form.
If PT samples are received in poor condition, the ALP should be notified immediately by email ([email protected]). The ALP may replace
samples, or an excuse from reporting results may be authorized.
All entries on forms and reports should be clearly typed or legibly written on the original.
Name and title of authorized person signing form should also be printed below signature on all forms and reports provided by the ALP.
Results may be submitted by mail or email. If submitting results by email, the original form must be signed. Digital signatures are
acceptable as well as pdf copies. The lab will receive an email confirmation from the ALP for submitting results via email. Please keep
this email for your records. If you do not receive an email confirmation within three business days, contact the ALP to verify that the results
were received.
PT sample results must be received on or before the due date indicated on the report form. Late results are subject to rejection.
Failure to report PT sample results could result in revocation of accreditation.
ALP will consider claims regarding PT sample results lost in the mail only with acceptable proof of mailing. Acceptable proof of mailing
includes receipts from the U.S. Post Office or overnight/express delivery carriers.
Requests for "Excused Absences" for PT sample results must be in writing, explain the reason for the request, and be received by ALP
at the address below before the due date.
Laboratories may not be excused more than twice per accreditation period. Any further requests to be excused will be reviewed on a
case-by- case basis by ALP staff.
If a laboratory believes that there was a data processing error in the PT report at FSIS, the laboratory may request a review. The
request must be in writing and received by ALP at the address below within 30 days of the data of the report in question.
Retain a copy of your PT Sample Results for your records.
All correspondence (including comments, suggestions, and appeals) should be addressed to:

Accredited Laboratory
ProgramUSDA, FSIS, OPHS,
LQARCSRussell Research
Center 950 College Station
RoadAthens, GA 30605

FSIS 10,120-1d (2023)

or

[email protected]

REPLACES FSIS 10,120-1 (02/02/2017) WHICH IS OBSOLETE

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