QC Worksheet for Urine Dipstick - Michigan



Urine Dipstick Quality Control Log Sheet

Albumin and Glucose only

Health Dept: ___________________________________ Site: ____________

Month: ___________________ Year: ________

Test Name: Urine Dipstick, albumin & glucose only

QC Data (reagent specifics)

| |Lot Number |Expiration Date |Expected Range Albumin |Expected Range Glucose |

|Low Control | | |to |to |

|High Control | | |to |to |

|Dipstick | | |na |na |

Q.C. Results

| | | |Observed |Pass/Fail |

|date |Initials |Control | | |

| | | |Albumin |Glucose | |

| | |Low | | | |

| | |High | | | |

| | |Low | | | |

| | |High | | | |

| | |Low | | | |

| | |High | | | |

| | |Low | | | |

| | |High | | | |

| | |Low | | | |

| | |High | | | |

Date Corrective Action: (use reverse side as needed)

| | |

| | |

| | |

| | |

_________________ ___/___/___ ____________________________ ____/____/____

Site Coordinator Date Laboratory Director/Technical Consultant Date

RLF-51 Rev. 6/9/2006

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