Photograph of Aspergillus niger spores.Mold Test Sample Chain of Custody Form
     


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Chain of Custody Form for Mold, Dust, Environmental Samples

Here we provide a free chain of custody form that readers can use to send environmental samples to any laboratory including our own.

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Mold, Dust, or Particle Sample Chain of Custody Form © 1986-2010 Daniel Friedman
Printer-friendly Chain of Custody Form
Tape Sample Mold, Dust, or Particle Collection Instructions
Bulk Samples: email to discuss sampling, packaging, processing, & fees

Environmental Testing, Paint Analysis, Art Conservation, Forensic Particle Identification, Indoor Air Investigations, Bioaerosols, Pollen, Mold, Mildew, Moisture. Mold Sampling & Laboratory Analysis

MAIL TO: [Mail this form with your sample to an environmental test lab of your choice. DO NOT send your sample to us without prior agreement.]
_______________________________________

_______________________________________

_______________________________________

D Friedman,m American Industrial Hygiene Association AHIA #149982 - Website: InspectAPedia.com®

Field Sample Chain of Custody

Client Name & Address to mail report

Site of Sample Collection

Collection Date

Address

Address

Project#

 

 

On Site From

 

To

 

 

Tel

Tel

Site Conditions

Email

 

Collected by

Received by

Processed by

Signature -  Date

Signature – Date

Signature – Date

 

 

Location

HE=high exposure/complaint area
LE=Low exposure/complaint area
Use one table  row to describe each sample.

Type
     A__Air/L3 V=Vac T=Tape  B=Bulk  S=Swab-in2
InspectAPedia®

Process

 Hold

 

Description / Comments

 

Accom-panying

Field

Photo

#

-1

 

Check one

HE__

LE__

 

 

 

 

 

-2

 

 

HE__

LE__

 

 

 

 

 

-3

 

 

HE__

LE__

 

 

 

 

 

-4

 

 

HE__

LE__

 

 

 

 

 

-5

 

 

HE__

LE__

 

 

 

 

 

-6

 

 

HE__

LE__

 

 

 

 

 

...

 

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CHAIN OF CUSTODY FORM for ENVIRONMENTAL SAMPLES at InspectApedia.com - online encyclopedia of building & environmental inspection, testing, diagnosis, repair, & problem prevention advice.

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