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


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?

***If no, explain in the comments section below what steps were taken to correct the inaccurate results.  (e.g. Repeated test, replaced meter, etc.)


Reason for Testing (Select from List)