Galson Labs

It is important to be able to trace samples from collection to data reporting so that the utmost confidence can be placed in the analytical results. A chain of custody is a mechanism for tracing the lineage of a sample from the time of collection through reporting of results to sample disposal.

The chain of custody is initiated by the sampler. As samples are passed from individual to individual, the transfers are noted. This process continues until the samples are delivered to the laboratory where the form is signed evidencing the date and time of sample receipt. The original chain of custody form is returned to the client with the analytical report, and a copy is retained with the project file by Galson Laboratories.

You have the option of either downloading a blank Chain of Custody form in Adobe Portable Document Format (PDF) or you may prefill the form below.

Once you have prefilled the form, click on the "Download the COC Form" at the bottom and click on "Open". This will let you check to make sure your information is accurate and complete. If it is complete, go to "file" and "save a copy". Then print this out and fax this to Galson and send in your original.

If you are checking your information and it's not accurate or complete, close the PDF file and just add the appropriate information to the input form and then click "Download the COC Form" and click on "Open". If it is complete, go to "file" and "save a copy". Then print this out and fax this to Galson and send in your original.

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Report To:



Phone No.:
Fax No.:

Invoice To:



Phone No.:
Fax No.:


Site Name:
Project:
Sampled By:

Need Results By:

Client Account No.:
Purchase Order No.:
Credit Card No.:
Card Holder Name:
Expiration Date:

Send Results To:
Email Address:
Fax Number:

Samples submitted using the FreePumpLoan™ Program
Samples submitted using the FreeSamplingBadges™ Program.

Sample Identification 1
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 2
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 3
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 4
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 5
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 6
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 7
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 8
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 9
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 10
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

Sample Identification 11
Identification:
Date Sampled:
Collection Medium:
Air Volume(Liters):
Passive Monitors(Min):
Analysis Requested:
Method Reference:
Specific DL Needed:

We normally add a laboratory blank for each analyte. We will charge you for this at our normal rate. If you agree please check “Yes”. Yes No

List description of industry or process / interference’s present in sampling area :

Comments :

When completing the Galson Chain of Custody form, please review the following defined terms:

"Sample Identification" is used to identify your samples in a unique form.

"Date Sampled" is the date samples were collected.

"Collection Medium" is the type of sampling media used to collect the samples. Tubes are usually numbered on the side and cassettes have a label stating what they are (i.e. preweighed (PW) PVC, or matched weight MCE)

"Air Volume" is calculated by taking collection time(min) x flow rate (LPM)

"Passive Monitors" is where you record the total minutes sampled for each passive monitor.

"Analysis Requested" refers to the analyte(s) you are looking to have analyzed (i.e. benzene, copper, ammonia, etc)

"Method Reference" is the method to be used for the analysis

"Specific DL Needed" should be completed if you are requiring a specific detection limit.