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Document No. 05 (01 Sep 17) Page 1 of 1 Customer: _______________________________ Date Sampled:................... _______________________ Contact Details (new customers or amendments) ..................Date Received: ________________________ Address: _____________________________________...............Time Received: ________________________ _________________________________________ Purchase Order:................. ________________________ Email: ____________________________________................Sampling Officer: _____________________ Tel: _________________ Fax: ________________............................. ..................................Signature: ..__________________________ Reason for Analysis: Product Testing Export Testing Shelf-life Testing Food Poisoning Food Survey Complaint (give details) Sample Type: Dairy Products Fish, Crustaceans and Molluscs Fruit and Fruit Products Vegetable and Vegetable Products Mixed Food Meat and Meat Products Poultry and Poultry Products Other - Specify Eggs and Egg Products * Environmental Swab Food Type Time Sample ID Brand Batch / UB Code Source Temp. (°C) _____________________________________________________________________________ ______ Laboratory Use Only Temperature on Receipt: _______°C Job Number: ______________ Registered by: _________ Public Health Laboratory 18 St Johns Avenue NEW TOWN Tasmania 7008 Phone: (03) 6166 1106 Facsimile: (03) 6230 7036 Email: Request for Bacteriological

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Page 1: Food Request · Web viewFood Poisoning Food Survey Complaint (give details) Sample Type: Dairy Products Fish, Crustaceans and Molluscs Fruit and Fruit Products Vegetable and Vegetable

Document No. 05 (01 Sep 17) Page 1 of 1

Customer: _______________________________ Date Sampled: _______________________Contact Details (new customers or amendments)........................................................

Date Received: ________________________ Address: _____________________________________ Time Received:

_________________________________________________________________Purchase Order:......... ________________________Email: ____________________________________ Sampling Officer: _____________________Tel: _________________ Fax: ________________ ........................................Signature: ......................................................__________________________

Reason for Analysis:

Product Testing Export Testing

Shelf-life Testing Food PoisoningFood Survey Complaint (give

details)

Sample Type: Dairy Products Fish, Crustaceans and Molluscs

Fruit and Fruit Products

Vegetable and Vegetable Products

Mixed Food Meat and Meat Products Poultry and Poultry Products

Other - Specify

Eggs and Egg Products

* Environmental Swab

Food Type Time

SampleID Brand

Batch / UB Code

Source Temp. (°C)

___________________________________________________________________________________Laboratory Use Only Temperature on Receipt: _______°C Job Number: ______________ Registered by: _________

Request for Bacteriological

Analysis of Food

Public Health Laboratory18 St Johns AvenueNEW TOWN Tasmania 7008Phone: (03) 6166 1106Facsimile: (03) 6230 7036Email: [email protected].

Page 2: Food Request · Web viewFood Poisoning Food Survey Complaint (give details) Sample Type: Dairy Products Fish, Crustaceans and Molluscs Fruit and Fruit Products Vegetable and Vegetable

Requested Testing Staphylococcus (coagulase +)

* Yeasts and Moulds

Standard Plate Count Bacillus cereus * EnterobacteriaceaeColiforms Salmonella spp. * Clostridium perfringensE. coli Listeria spp. * Campylobacter spp.Vibrio parahaemolyticus Listeria monocytogenes * Other - Specify

* Test is not NATA-accredited

Comments:

___________________________________________________________________________________Laboratory Use Only Temperature on Receipt: _______°C Job Number: ______________ Registered by: _________


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