APPENDIX A (part 1)
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)
Phone (740) 779-7655
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.
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
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
Phone: (937) 981-9271
For Laboratory Use Only
Time of specimen receipt: ____________________________________
Type of vial or collection device:_______________________________
Other notes of importance:____________________________________