Free 2196 - Federal

LABORATORY MANAGEMENT CODING SHEET
ANALYZING DISTRICT SAMPLE NUMBER PAC CODE LID CODE DELETE (Y or BLANK)

SAMPLE FLAG

SAMPLE TYPE

CF NUMBER

STATE CODE

COUNTRY OF ORIGIN

HOME DISTRICT

PRODUCT CODE

DATE COLLECTED

COLL DIST

SAMPLE DESCRIPTION

DATE AVAILABLE

LABELING ONLY (Y or BLANK)

BACKLOG LAB

ANALYST TYPE

EMPLOYEE NUMBER

* POS CLASS

* EMPL
HD

EMPL LAB

DATE ASSIGNED

ANALYST TIME

DATE COMPLETED

* Code only for
Detailed Employee

LABORATORY CLASSIFICATION

DATE OUT OF LABORATORY

FORM TYPE

VIL

THE INFORMATION IN THIS SECTION NECESSARY FOR VIOLATIVE SAMPLES (LAB CLASS 3)

RESPONSIBLE FIRM NAME * CITY, STATE REASON FOR VIOLATION

Use for continuation of "REASON FOR VIOLATION"

FORM TYPE NAR USER FLAG

NARRATIVE INFORMATION

FORM FDA 2196 (7/87) PREVIOUS EDITION OBSOLETE

PSC Media Arts (301) 443-1090

EF