FOOD MICROBIOLOGY Request Form for Microbiological Analysis of FOODS Name of Sampling Officer Client Order No/Client Project Identifier DATE?TIME RECEIVED AT LAB: DATE/TIME SAMPLED BY HPO: Temp ºC __________________ Temp ºC __________________ HEALTH CONTRACT PHSP YES/NO COMMERCIAL STATUTORY (OFFICIAL SAMPLE) YES/NO YES/NO Job No: NAME AND ADDRESS FOR REPORT FAX NO: PHONE: PROJECT IDENTIFICATION (Please tick appropriate box) Suspect Food Poisoning (F12) Domestic Food Monitoring (F13) Food Complaint (F12) Imported Food Surveillance (F14) SAMPLE Other MoH Project Code............................................... Project Name ................................................................ Commercial Others FOOD CATEGORY: Information to support analysis: ___________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ IMPORTED FOODS - COUNTRY OF ORIGIN: TESTS REQUIRED: CHOOSE STANDARD TESTS OR OTHER RELEVANT TESTS STANDARD TESTS as specified in: For non-standard tests, please select relevant tests only. Consult laboratory if necessary. DO NOT TICK ALL BOXES Food Poisoning organisms Food Regulations 1984: Salmonella Toxins - Schedule.................................. Aerobic Plate Count (35ºC) Campylobacter Yeast and Mould - Regulation............................... Micro Reference Criteria - Criterium No ......................... Tests in project specification LAB NO. Coliforms/Faecal Coliforms Coagulase producing Staphylococcus Clostridium perfringens Bacillus cereus CLIENT REF NO. BATCH NO NAME AND SIGNATURE OF SUBMITTING OFFICER: Listeria monocytogenes Yersinia enterocolitica Escherichia coli Vibrio parahaemolyticus Commercial Sterility DESCRIPTION OF SAMPLE ________________________________ Continued overleaf LAB NO. CLIENT REF NO. ESR Public Health Laboratories Christchurch ESR Christchurch Science Centre 27 Creyke Road PO Box 29-181 CHRISTCHURCH Phone: (03) 351 6019 Fax: (03) 351 0010 BATCH NO DESCRIPTION OF SAMPLE
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