CONTRACT TEST SERVICE			
Sample Submission Form __________________________________________________________________________________________
COMPANY NAME:	     		Laboratory Use Only	
CONTACT NAME:	     		Internal Control Number:		-		
NUMBER OF SAMPLES IN SHIPMENT:	     		Customer ID Number:		
				
By submitting this Sample Submission Form (SSF) and sample(s) to the Associates of Cape Cod, Inc. (ACC)
Contract Test Service (CTS) Department, you are authorizing the analysis of your sample(s) as indicated on
the SSF and according to ACC Standard Operating Procedures.	

Sample Identification*	Lot
Number	Concentration
or Maximum Dose	Endotoxin Limit	Storage Temp.**	Report EU per
mg, mL, or device
(Check box)	
     	     	     	     	     	mg   mL   device	
     	     	     	     	     	mg   mL   device	
     	     	     	     	     	mg   mL   device	
     	     	     	     	     	mg   mL   device	
     	     	     	     	     	mg   mL   device	
     	     	     	     	     	mg   mL   device	
*If additional space is required, use multiple forms.
** If no storage temperature is indicated, the samples will be stored refrigerated.

TYPE OF SAMPLE	
 Biological	 Medical Device	 Pharmaceutical	 Other:	     	
 Biotech	 Parenteral	 Polymer	 Serum:	     	
 Chemical	 Nanoparticles (Nanotubes   
     and Nanofibers)
	 Water	 Controlled Substance*	 Yes	 No	
 Intrathecal		 Tissue	*Note: Request DEA Form 222 and provide current copy of DEA License to CTS.	

TEST TYPE	
 Product Characterization
    (Preliminary Screening)	 Inhibition/Enhancement
   (Validation)	 Release (Limit) – Finished Product	
 Method Development		 Release (Limit) – Components/ Raw Materials	
TEST ASSAY – SELECT ASSAY TYPE	
Gel-clot 	Turbidimetric	Chromogenic	Chromogenic	
 Gel-clot Assay	 Kinetic Assay	 Pyrochrome®	 Chromo-LAL Kinetic Assay	
	 Endotoxin Specific	 Endotoxin-Specific	 Kinetic Assay (LOQ=0.005 EU/mL)	 Glucatell® Kinetic Assay	
			 Endotoxin Specific (LOQ=0.001 EU/mL)	(Glucan Specific, Research Use Only)	

INSTRUCTIONS	
a	When sending multiple samples from one lot, indicate the following:	 Test Samples Individually	 Test Samples Pooled	
a	For product release, list IC numbers of validations (if known):	     	
a	Recommended method for reconstitution or extraction:	     	
a	Handling precautions:	     	
a	Recommended method of sample disposal:	     	
a	Special Instructions:	     	
a	Send MSDS for sample (or letter stating handling precautions). If not included, no testing will be performed until received.	
a	Expedited Services: 	RUSH test service – 48 hour study initiation 	 Yes	 No	
		STAT test service – 24 hour study initiation 	 Yes	 No	
Comments:      	
CONTRACT TEST SERVICE			
Sample Submission Form
INTERNAL CONTROL NUMBER:		-		

BILLING INFORMATION		REPORTING INFORMATION	
Company Name:	     		Company Name:	     	
Attention:	     		Attention:	     	
Address:	     		Address:	     	
	     			     	
	     			     	
Phone:	     		Phone:	     	
Fax:	     		E-mail:	     	
					
Please Check Method of Payment:				
 Purchase Order Number:	     		Reports:		
Credit Card:	 Visa	 MasterCard	 American Express		An original report will be sent by mail to the above address.  A PDF copy will be e-mailed.	
	Number:	     				
	Security Code:	     		E-mail (PDF – non encrypted)	
	Expiration Date:	     		 Report Only	
	Name on Card:	     		 Report and Raw Data	
	Signature:	     				
					
SHIPPING INFORMATION		CONTACT INFORMATION	
*Samples should be sent to the following address:		Phone:  508-540-3444 or 888-232-5889	
	Contract Test Service		Fax:  508-540-2019	
	Associates of Cape Cod, Inc.				
	124 Bernard E. Saint Jean Drive		Website:  www.acciusa.com/cts	
	East Falmouth, MA  02536				
*Details for shipping samples can be found in the CTS Pricelist or on our website:  www.acciusa.com/cts		Email:  testservice@acciusa.com	

INTERNAL USE ONLY	
Sample/package condition upon receipt:	
	Physical condition:	 Good	 Damaged	Technician Initials:		Date:		
	Arrival Temperature:	 RT	 Cold	 Frozen	Storage Temperature:	 RT	 2°-8°	 -20°C	 -80°C	
Number of Samples Received:		Agreement with number shipped:	 Yes	 No	
Sample Status:	 Acceptable; no action required.	 Requires Customer Notification.	
Reason for Notification:	 Sample Leaking	 Sample missing	 Inappropriate arrival temperature	 Lot Number Discrepancy	
 Other* -	*Explanation:		
	
Name of Customer Contact:		Date:		Contacted by:	 Phone	 E-mail	
Comments/Resolution:		

Action Required:		
	
If additional space is required, attach a separate sheet.				
						
				Verified by:		
CTS Staff Name		Date			Initial/Date