Sample Comparison Form
for Bilicheck, Hemoglobin, Hematocrit, HBGA1C, and INR

  
 
 

  Month:      Year: 
 
 POC Test:    
Site or Clinic:     

Please use your Reference Lab Report to provide the information below.

Collection Date:              

POC Result:   Reference Lab Result:     

ACCURACY % (Please leave this field BLANK)

________________________________ OTHER____________________________________

1. Has the appropriate maintenance and Quality Control been performed and documented ? Yes No   N/A
   

2.  Has competency been documented for all personnel performing the test? Yes No

Submitted by:       Date:    

 
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