Glucose QA Data Submission Form
Results Page | Submission Form | Database Editor



Date
 

Shop Number (Enter the Four Digit ID#)
 

Person Performing Test (Enter First and Last Name)
 

Key Date AmbShopNum PersonPerformingTest MeterSerialNumber HiControlLotNum HiControlExpiration HighControlDateOpened LoControlLotNum LoControlExpiration LoControlDateOpened TestStripLotNum TestStripExpirationDate TestStripCode HighControlResult HighControlLow HighControlHigh LowControlResult LowControlLow LowControlHi TestInRange Comments TestReason
 


Meter Serial Number (Found on the back of the meter.  Select the number from the list.)

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)