Manifest Report

PATIENT DEMOGRAPHICS
Production or Group Name*
Testing Date*

DayMonthYear
DD-MM-YYYY
Specimen collection method*
Location (City)*
Please specify all testing devices used*

Viral Transport Medium (PCR)Abbott Panbio COVID-19 Ag (RAT)Abbott ID Now ™ (MOL)Lucira ™ Check It COVID-19 Test Kit (LUC)Sofia ® 2 Flu+SARS Antigen FIA (SOF)Virtual Antigen TestingSD Biosensor (RAT)
Did Production supply you with their own Rapids/Moleculars

YesNo
Total Number of PCRs
Total Number of Abbott Panbio (Rapid Antigens)
Total Number of Lucira Check-It (Moleculars)
Total Number of Abbott ID Now (Moleculars)
Total Number of Sofia Flu+SARS (Rapid Antigens)
Total Number of Virtual Antigen Tests
Upload Paper Manifest HERE*

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Upload Pictures of Resulted Rapid Testing Devices (RAT/MOL/LUC/SOF) HERE

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RESULTS (RAPID ANTIGENS READ AT 15min MARK)
Please state "ALL NEGATIVE". Or, if any POSITIVES found, please message KELSI MAYNE (615) 582-1448, the production's COVID supervisor, and list Name and DOB of POSITIVE here.
Testing Lot Number for Testing Devices*

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Name of clinician performing & reading the test*
Designation of clinician performing the test & licence number*
Email (Please input your email if you wish to receive a summary of your submission)
example@example.com
Production Testing Start Time (Not Including Travel)*

Military Time
Production Testing End Time (Not Including Travel)*

Military Time
Upload Paper Consent Forms (If any)

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Additional notes (if needed)
ie.) Number of tests wasted and reason, any complications, any concerns, if this is a late entry, etc.
Signature of clinician performing the test*

Clear
Pulsar UV Inc.
50-152 Thirtieth St, Etobicoke, ON M8W 3C4
Phone: (647) 696-8800 info@pulsaruv.com
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