Specimen Tracking Form
Meconium
ARUP Test #: 0092516 / Cord
ARUP Test #: 2006621 / Serum/Plasma / Urine / Other

Client Name:

Client Number:

Patient or Infant Name:

DATE
/
RELEASED BY/FROM
/
RECEIVED BY/IN
/
PURPOSE OF CHANGE
__/___/__ / Signature
------
Print name / REFRIGERATOR /

SECURE STORAGE

__/___/__ / Signature
------
Print name / Signature
------
Print name
__/___/__ / Signature
------
Print name / Signature
------
Print name
__/___/__ / Signature
------
Print name
__/___/__ / Signature
------
Print name
__/___/__ / Signature
------
Print name /

TRANSIT BAG

__/___/__ / Signature
------
Print name /

TRANSIT BAG

/

TRANSPORT TO ARUP

  • It is expected that only the relevant lines of this form will be completed.
  • Instructions for completing this form are printed on the back side of the form.
  • Receipt of this form and related specimen, as well as subsequent testing, reporting, and storage will be documented electronically by ARUP Laboratories.

Instructions for completing the ARUP Specimen Tracking Form

1.Initiate and complete the Specimen Tracking Form to reflect the time at which a specimenis collected, until the specimen is transported to ARUP Laboratories for testing. The form must be completed to accurately reflect and substantiate the processes involved in specimen collection and transport.

2.Print at least two labels with standard patient identification information; adhere one to an empty specimen container and one to the Specimen Tracking Form in the box indicated.

3.Obtain a specimen to test.

4.Transfer the specimen into the labeled specimen collection container. .

5.Transport specimen container and completed Specimen Tracking Form to ARUP.

The Specimen Tracking Form has several pre-populated options indicated below by letters “A” through “E.” The individual lines are intended to be used when documenting:

  1. Specimen collected and then stored in a refrigerator (in a secure location) to await additional collections or processing (such as ordering the test and arranging for transport)
  2. Additional transfers of responsibility for specimen collection, handling, etc., between two people
  3. Additional transfers between a person and a location (refrigerator, bag, local laboratory, etc.)
  4. Sealing the specimen container and placing it in a transit bag that will be used to transport the specimen to a local or central laboratory that coordinates transport to ARUP
  5. Sealing the specimen container and placing in a bag that will be transported directly to ARUP

DATE
/ RELEASED BY/FROM / RECEIVED BY/IN / PURPOSE OF CHANGE
The date,mo/day/yr, on which the task to be documented is performed / Any staff member involved in the collection, handling, storage, and preparation for transport of the specimen should be named (printed to be legible on the lower line), and signature included (on the line above the printed name). / An additional staff member or location (refrigerator, transit bag, other) to which the first staff member transfers responsibility related to the collection, handling, storage, or preparation for transport of the specimen should be named as described in “RELEASED BY/FROM.” /

Document the task performed:

EXAMPLES:

1.Secure storage (e.g., laboratory, refrigerator)

2.Transport to alternate location such as a local or central laboratory that coordinates transport to ARUP

3.Transport to ARUP

A / Signature
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Print name / REFRIGERATOR /

SECURE STORAGE

B / Signature
------
Print name / Signature
------
Print name
C / Signature
------
Print name
D / Signature
------
Print name / TRANSIT BAG
E / Signature
------
Print name / TRANSIT BAG / TRANSPORT TO ARUP

CORP-FORM-5076F, Rev 0 | October 2013 | Page 1 of 2