www.esr.cri.nz
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
Kenepuru Science Centre: 34 Kenepuru Drive, Kenepuru, Porirua 5022 | PO Box 50348, Porirua 5240, New Zealand
T: +64 4 914 0700 F: +64 4 914 0770
LABORATORY SERVICES REQUEST FORM
ENVIRONMENTAL WATER SAMPLE TESTING
For Legionella, Mycobacterium, Pseudomonas and Heterotrophic Plate Counts
Samples must reach the laboratory within 24 hours of collection
CLIENT INFORMATION
Time sent:
Date sent:
Client order no:
Name of sampling ofcer:
NAME AND ADDRESS FOR REPORTING
Address:
Email:
Contact:
Phone:
Name:
Case’s EpiSurv no:
RESET FORM
TYPES OF SAMPLES
Drinking water Cooling tower water
Please tick appropriate box(es)Please chill samples 4°C to 10°C
REASON FOR TESTING
TESTS REQUIRED
Routine monitoring Outbreak investigation Repeat testing
Source tracing Clearance testing
Other (specify):
Please tick appropriate box(es)
Please tick appropriate box(es)
Date received: Time received:
ESR USE ONLY
Condition of sample on receipt:
Other:
*KEY choose from
options below
SOURCE OF SUPPLY
1 Unknown
2 Well/Bore
3 River or Stream
4 Reservoir
5 Water Race, Canal
6 Roof run-off
7 Spring
8 Geothermal
TYPE OF SUPPLY
11 Unknown
12 Spring Head
13 Well Head
14 Building
Reticulation
15
Ornamental Water
Feature
16 Bulk Storage Tank
17 Header tank
TREATMENT TYPE
21 Unknown
22 Chlorine biocide
23 Bromine biocide
24 Ultra Violet
25 Silver-Copper
Ionisation
26 Filtration
27 Heat
UT Untreated
ESR Lab No. Client Ref No.
Date and time
sampled
Sample Site
Water Sample Information
Volume Source* Type* Treatment* FAC Temp ⁰C
ESR0592
vers 5.0 July 2018
Non potable water Swimming/Spa pool water
Other (specify):
Legionella isolation Legionella identication
Mycobacterium isolation Mycobacterium identication
Pseudomonas isolation Pseudomonas identication
Heterotrophic plate count (21°C / 36°C)
INSTRUCTIONS FOR USING FILLABLE FORMS:
In Acrobat Reader, please complete this form, then ‘SAVE AS PDF’
to your hard drive. Email to KSC.Legionella@esr.cri.nz
Print out your form and send to ESR with your specimen.
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