Food and Environmental Proficiency Testing Unit
Laboratory identification no. (check): / Please enter your lab number
Dispatch date: / 12 March 2018
Final date for return of results: / 06 April 2018
Contact details:
The Organisers - FEPTU
Public Health England
61 Colindale Avenue,
London, NW9 5EQ, UK.
Fax: +44 (0) 20 8200 8264
Tel: +44 (0) 20 8327 7119
e-mail: /
0006
www.gov.uk/government/collections/external-quality-assessment-eqa-and-proficiency-testing-pt-for-food-water-and-environmental-microbiology#dialysis-water-scheme
Dialysis Water Scheme Request/Report Form
Distribution No: DW15 / Sample numbers: DW15A and DW15B
Download the sample instruction sheet. A video on sample processing is located further down the webpage: / www.gov.uk/government/publications/dialysis-water-scheme-sample-instruction-sheet
Download the safety data sheet: / www.gov.uk/government/publications/safety-data-sheet-for-lenticules
If you cannot examine any of these return your results as ‘Not examined’
Sample type: / Water sample collected three hours ago from a sample port in the distal segment of the loop of the dialysis machine.
Results:
Sample Number / Enumeration / Not examined / Result / Conclusion reported to the sender(Please tick any that apply)
DW15A / TVC
17ºC - 23ºC for 7 days per mL / o / Satisfactory/Acceptable / o
Unsatisfactory/Unacceptable / o
Borderline / o
Breaches action level / o
Not routinely reported / o
Meets the maximum admitted value / o
Satisfactory/Triggers action level / o
Other, please state / o
Food and Environmental Proficiency Testing Unit
Laboratory identification no. (check): Please enter your lab number
Sample Number / Enumeration / Not examined / Result / Conclusion reported to the sender
(Please tick any that apply)
DW15B / TVC
17ºC - 23ºC for 7 days per mL / o / Satisfactory/Acceptable / o
Unsatisfactory/Unacceptable / o
Borderline / o
Breaches action level / o
Not routinely reported / o
Meets the maximum admitted value / o
Satisfactory/Triggers action level / o
Other, please state / o
Please indicate the method used / o / Pour
o / Membrane filtration
o / Spread
o / Other
Please indicate the media used / o / Tryptone glucose extract agar (TGEA)
o / Yeast extract agar(YEA)
o / R2A agar
o / Tryptone soya agar (TSA)
o / Other
Standard/Guideline followed / o / ISO 13959:2014
o / ISO 23500:2014
o / ISO 11663:2014
o / ISO 6222:1999
o / European Best Practice Guidelines for Haemodialysis
o / UK Renal Association guideline
o / Public Health England guideline
o / European Pharmacopoeia
o / Other
Additional comments
Authorised by: Date reported:
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