Laboratory Specimen Collection Checklist Form
Complete this checklist to ensure accurate and compliant specimen collection for laboratory analysis.
Patient or Sample ID
*
Date of Collection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Collection
*
Hour Minutes
AM
PM
AM/PM Option
Type of Specimen
*
Please Select
Blood
Urine
Saliva
Tissue
Swab
Other
Collection Site
*
Please Select
Arm (Venipuncture)
Fingerstick
Mouth
Nasal
Urine Collection
Other
Collection Method
*
Please Select
Standard
Sterile Technique
Aseptic Technique
Other
Container Type
*
Please Select
Vacutainer
Sterile Cup
Swab Tube
Slide
Other
Labeling Confirmed
*
Yes
No
Special Instructions (if any)
Collector’s Full Name
*
First Name
Last Name
Submit Checklist
Should be Empty: