APPENDIX A (part 1)


How to Collect Semen Specimens for Fertility Analysis,

Semen Analysis, or for Post-Vasectomy Evaluation


Specimens collected for post-vasectomy may be submitted to the laboratory system at any time and at any lab site.  However, specimens collected for fertility analysis or complete semen analysis may only be submitted to the hospital laboratory and must be submitted within one hour after collection. If a patient/client has any questions, please call the hospital laboratory at (740) 779-7655 and ask to speak with the Hematology Supervisor.


Instructions for specimen collection:

1.                   Patient must abstain from sexual relations for two to seven days prior to collection of sample.


2.                   Collect specimen by masturbation into a clean, dry jar or vial.  Avoid the use of lubricants.


3.                   Specimen vials may be picked up at any laboratory location (see back of this form for laboratory locations).


4.                   The total ejaculate must be in the container.  If any of the ejaculate is lost, the specimen should be recollected at another time.


Semen specimens for fertility or complete analysis must be maintained at room temperature and brought to the hospital laboratory within one hour after collection.  Please label the container with your name and the time of collection.  Specimens for post-vasectomy evaluation should be submitted as soon as possible.  Please inform the laboratory staff if your sample has been exposed to temperatures other than room temperature.


 Please answer the following questions and bring this form with the specimen.


Patient Name: _______________________________________________________


Date and time of collection: ____________________________________________


Number of day’s abstinence: __________ day(s)


Was the sample kept at room temperature? (Circle one)   Yes           No

If No, briefly mention how the sample was exposed to extreme hot or cold conditions? ___________________________________________________________









APPENDIX A (part 2)


  1. Chillicothe:  Adena Medical Center, Laboratory Department at 272 Hospital Road.

          Phone (740) 779-7655


  1. Chillicothe:  Adena Health Center at 55 Centennial Blvd.

          Hours are 7 am to 8 pm Monday through Friday, 8 am to 8 pm on Saturday, and                 10 am to 8 pm   on Sunday.  Phone:  (740) 779-4018.


  1. Waverly:  Adena Health Center at 12340 State Route 104.

          Hours are 7 am to 8 pm Monday through Friday, 8 am to 8 pm on Saturday, and                 10am to 8pm         on Sunday.  Phone: (740) 941-5159


  1. Jackson:  Adena Health Center at 1000 Veterans Drive.

                Hours are 7:30 am to 8 pm Monday through Friday, 10 am to 6 pm Saturday, and                10am    to 6pm on Sunday. Phone:  (740) 286-9040


  1. Greenfield:  Adena Greenfield Medical Center at 550 Mirabeau Street.

          Phone: (937) 981-9271




For Laboratory Use Only

Time of specimen receipt: ____________________________________


Type of vial or collection device:_______________________________


Other notes of importance:____________________________________