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Reagent Lot Check-In for [Instrument/Assay Name]

Test_________________ Date_____________ Tech ______________

Old Lot New Lot

Lot # _________________ __________________
Exp. Date _________________ __________________
Rec’d Date _________________ __________________
Calib. Lot # _________________ __________________
Date Calib. _________________ __________________

Calibrator Data
Low Cal Conc _________________ __________________
Mean RLU _________________ __________________
CV% _________________ __________________
High Cal Conc _________________ __________________
Mean RLU _________________ __________________
CV% _________________ __________________

QC Material

Control Value SDI Value SDI Target SDI

1 ______ ______ ______ ______ ______ _________

2 ______ ______ ______ ______ ______ _________
3 ______ ______ ______ ______ ______ _________
4 ______ ______ ______ ______ ______ _________

Current Status Mean SD CV 2SD Range

1___________ ______ ______ ______ ____________

2___________ ______ ______ ______ ____________
3___________ ______ ______ ______ ____________
4___________ ______ ______ ______ ____________
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Patient Correlation
Accession No Value RLU Value RLU

1. ___________ ______ ______ ______ ______

2. ___________ ______ ______ ______ ______
3. ___________ ______ ______ ______ ______
4. ___________ ______ ______ ______ ______
5. ___________ ______ ______ ______ ______
6. ___________ ______ ______ ______ ______

Acceptability Factor: ___________ Range < 2.0

Lead Tech Review: ____________________________________ Date: ____________________

Supervisor Review: ____________________________________ Date: ____________________