MICROBIOLOGICAL MONITORING SAMPLE LOG
MICROBIOLOGICAL MONITORING SAMPLES (RODAC) LOGCOMPARATIVE MEDICINETO BE COMPLETED BY PERSON TAKING SAMPLESSITE(Circle One) ALZ COM SRB VA PSY CPH IDRB DATE OF SAMPLING _________________ SAMPLES TAKEN BY __________________________________ TIME OF SAMPLING __________________REASON FOR SAMPLING (CHECK ONE BELOW) SUPERVISORS INITIALS ______________ 2057400736600036423607366000266700736600059436007366000 RQ ROUTINE QUARTERLY RS ROOM SANITIZING RT RETEST (Used only for prior Marginal OT OTHER or Unsatisfactory Results) COLUMNS 1 AND 2 TO BE COMPLETED BY PERSON TAKING SAMPLES SAMPLECODE & # 1 or 2*SEE BELOWFOR CODESROOM #orSOURCE(USE CW FOR CAGEWASH)SHELF#COLONYCOUNTGRAM -RODSGRAM+COCCIRATINGE- ExcellentA- AdequateM- MarginalU- Unsatis- factoryREMARKS /COMMENTS(NOTE: FACILITY MANAGER MUST BE NOTIFIED OF ANY MARGINAL OR UNSATISFACTORY RESULTS WITHIN 48 HOURS OF RECORDING) COLUMNS 3 THROUGH 8 TO BE COMPLETED BY THE COM MANAGER OR DESIGNEETO BE COMPLETED BY COM MANAGER/DESIGNEE:DATE SAMPLING RECEIVED________________ SAMPLING & RESULTS RECORDED TIME SAMPLING RECEIVED_________________ BY ______________________________SAMPLE CODES FOR COLUMN 1RM – ROOM WALL RK – CAGE RACK MC – MOUSE CAGERC – RAT CAGEST – SIPPER TUBEWF – WIRE FEEDER WB – WATER BOTTLEWS – WATER SOURCENHP–PRIMATE CAGEGP – GUINEA PIG CAGE RB – RABBIT CAGEOT – OTHER (Must be described in remarks) (Each sample must show either first or second sample i.e., RM1 would be first sample from room wall; RM2 would be second sample from same room wall)EACH SAMPLE ACCOMPANYING LOG MUST HAVE FULL DATE AND TIME OF SAMPLE, SITE, SOURCE, SAMPLE CODE & NUMBER LEGIBLY RECORDED ON SIDE OF LOWER HALF OF RODAC PLATE OR SWAB CONTAINER LABEL. Example: 1/15/12 3:52p.m. COM CW WF1 ................
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