SURVEY FORM FOR TRANSPORT & DELIVERY OF 2021 NEQAS - CC SAMPLES
Please check for the completion of the package. Answer the survey as completely as possible by checking and filling-up the appropriate response for each field.

NOTE: Please submit this form within 2 weeks after receiving the NEQAS Samples, so that concern may be properly addressed.
Name of Clinical Laboratory (based on your latest License to Operate) *
Complete Laboratory Address *
Region *
I. Receipt of NEQAS-CC Samples
a. Date of Receipt *
MM
/
DD
/
YYYY
b. Mode of Delivery *
c. Received by *
d. Designation *
II. Inspection of the Package
a. Is it properly and securely packed? *
b. Is it properly and completely labelled? *
c. Is it handled properly by the official courier/staff? *
Remarks
III. Inspection of Samples
a. Are the samples properly and completely labelled? *
b. Are the vials complete? (total of 12) *
*If incomplete, how many are present?
*If incomplete, what sample number is missing?
c. Are the vials sealed and intact? *
If not, describe the problem
(ex. Broken vial; mislabelled or tampered label)
d. Are the vials properly and completely labelled? *
IV. Others
Documents
Are you satisfied with how it is packed? *
*If not, state the reason why
Accomplished by:
Name of the Clinical Laboratory Staff *
Designation *
Date Accomplished *
MM
/
DD
/
YYYY
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