BEL LAB SAMPLE SUBMITTAL FORM
Name
Phone
Affiliation
Address
Fax
Study Name
Average length of time samples have been stored previous to shipping
Storage Temperature
Date samples sent
Number of samples sent
Collection Method (Circle all that apply)
No Stimulant
Trident (Original Flavor)
Salivette
Cotton Roll (Specify Brand)
Kool-Aid (Specify amount used)
Other (Specify)
*NOTE: Please attach a roster listing the identification number of each sample and include this material in your shipping package.
************FOR BEL USE ONLY ************
Date Samples Arrived
Number of Samples Received
Did samples arrive frozen?
Discrepancies with samples received and roster
Storage area
Date Tested
Date Discarded
Technician who checked in samples
Technician who ran assays
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