LABORATORY SAMPLE ANALYSIS REQUEST AND SAMPLE SEAL

AUTHORITY:

POLICY: It is the policy of the Division of Occupational Safety and Health to ensure the integrity of all samples taken by compliance personnel in the field when submitted to the laboratory for analysis by preserving an unbroken chain of custody between compliance personnel who collect the sample in the field and the laboratory which analyzes the sample.

PROCEDURES:

A. DISTRICT RESPONSIBILITIES

1. Compliance personnel are responsible for correctly completing and reviewing for accuracy the Cal/OSHA Form 1H before transmitting any samples obtained in the field to the laboratory.

2. If compliance personnel check Item 9 for Urgent Lab Services, compliance personnel shall obtain the approval of the District Manager prior to sending the Form 1H along with the sample(s) to the laboratory.

3. Compliance personnel shall ensure that prior to mailing the sample(s) they are appropriately sealed with Samples Seals (1HS).

4. Office Support Staff shall mail the sealed sample to the laboratory for analysis together with the Form 1H.

5. Office Support Staff shall file a copy of the Form 1H in the employer's case file.

B. Cal/OSHA FORM 1H COMPLETION

Page ____ of ____

Number each page and indicate the total number of pages.

1. SE/IH

   Check the appropriate box to indicate if you are a safety engineer or an industrial hygienist.

2. Region and District

   Indicate the number of the Region and District.

3. Date Submitted

   Enter the date that the sample(s) was/were submitted to the laboratory.

4. Name

   Enter your name.

5. Phone No.

   Enter a telephone number where you can be reached.

6. FAX No.

   Enter a FAX number where information can be sent to you.

7. Inspection Identification

   Enter your ID Number, Optional Report Number and Fiscal Year.

8. Sample Information

   Enter a field sample number corresponding to the number entered on the 1HS (Sample Seal), the date the sample was collected, the type of sample, the volume, any relevant field information and the analysis requested.

9. Urgent Lab Service Request

   Check if laboratory service is urgent and have the District Manager initial the Urgent Lab Service Request.

10. Comments

    Enter any information about the samples which would be helpful to the laboratory in processing your sample request.

11. Custody Record

    To be filled in by every individual who releases or receives the sample including the date and time.

12. Date Received by Lab

    To be filled in by the laboratory.

13. Status of Sample Seals

    To be filled in by the laboratory.

C. Cal/OSHA FORM 1HS COMPLETION

1. SE/IH Identification Number

   Enter your ID number, Optional Report Number (corresponding to the number entered in the Form 1H) and Fiscal Year.

2. Field Sample Number

   Enter a number for each sample to be analyzed corresponding to the number entered in the Form 1H.

3. Date

   Enter the date the sample was collected.

4. Collected By

   Sign your name in the space provided.

Attachments:

A -- Cal/OSHA 1H
B -- Cal/OSHA 1HX
C -- Cal/OSHA 1HS