Date
Shop Number (Enter the Four Digit ID#)
Person Performing Test (Enter First and Last Name)
Meter Serial Number (Found on the back of the meter. Select the number from the list.) R-F083-63369 T-H024-60562 R-F088-60038 R-F088-60068 R-F088-60133 R-F088-60148 R-F088-60161 R-F088-60170 R-F088-60171 R-F088-60174 T-F291-60325 R-F091-60067 R-F091-60259 T-G176-64826 T-G176-64619
High Control Lot Number Low Control Lot Number
High Control Expiration Date Low Control Expiration Date
High Control Date Opened Low Control Date Opened
Test Strip Lot Number Test Strip Expiration Date Test Strip Code
High Control Test Result High Control Low High Control High ----
Low Control Test Result Low Control Low Low Control High ----
Were both high and low test results within the range specified on the bottle of test solution? YesNo
***If no, explain in the comments section below what steps were taken to correct the inaccurate results. (e.g. Repeated test, replaced meter, etc.)
Comments
Reason for Testing (Select from List) Monday Check New Vial of Test Strips Opened Meter Was Dropped Vial of Test Strips Was Left Open Meter Used for the First Time Other