Laboratory Exam Checklist Form
Use this form to document laboratory exam details, verify checklist items, record observations, and confirm completion.
Sample and Exam Details
Patient or Subject Reference Code
*
Department or Unit
*
Please Select
Hematology
Chemistry
Microbiology
Pathology
Immunology
Molecular Diagnostics
Other
Exam or Test Name
*
Specimen Type
*
Please Select
Blood
Urine
Stool
Sputum
Saliva
Swab
Tissue
Other
Sample Collection Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Requesting Clinician or Technician Name
*
Priority
*
Routine
Urgent
Stat
Accession or Tracking Number
*
Checklist and Readiness Verification
Specimen Label Verified
*
Yes
No
Not Applicable
Container Type Correct
*
Yes
No
Not Applicable
Sample Volume Sufficient
*
Yes
No
Not Applicable
Transport Conditions Met
*
Yes
No
Not Applicable
Requisition Form Attached
*
Yes
No
Not Applicable
Equipment Calibrated
*
Yes
No
Not Applicable
Reagents Available
*
Yes
No
Not Applicable
Chain of Custody Noted
Yes
No
Not Applicable
Safety and PPE Compliance
*
Yes
No
Not Applicable
Results, Observations, and Completion
Preliminary Result Status
*
Pending
In Progress
Completed
Rejected
Rerun Needed
Result Summary / Observations
*
Abnormal Flags
Hemolysis
Lipemia
Icterus
Clotted Specimen
Instrument Alert
Out of Range
Other
Corrective Action Needed
Reviewer / Verifier Name
*
Verification Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Final Completion Status
*
Please Select
Completed
Completed with Notes
Needs Review
Rejected
Rerun Needed
Submit
Should be Empty: