Vial Performance Form
Must be completed by Physician's Office performing the procedure
Donor Number
*
4 digit donor number
Specimen Date
*
-
Month
-
Day
Year
Date
Vial Number
*
Specimen Type
*
IUI
ICI
IUI ART
ICI ART
ICSI-W
ICSI
IVF
Was the specimen washed prior to analysis?
*
Yes
No
Was the specimen mixed before analysis?
*
Yes
No
If yes, how?
*
Inverted several times
With a pipette
Vortex
Other
Post Thaw Information
Concentration after thaw
*
million/mL
Motility after thaw
*
%
Vial volume
*
mL
Was CASA used for counts?
*
Yes
No
I verify that the above information listed above is reported prior to washing or further processing.
Name
*
First Name
Last Name
Email
*
example@example.com
Clinic Code
*
6 digit clinic code
Submit
Should be Empty: