Clinical Microbiology Proficiency Testing
Department of Pathology and Laboratory Medicine   University of British Columbia
Room 328A, 2733 Heather Street, Vancouver, British Columbia, Canada, V5Z 1M9
Telephone: 604-875-4685 or 1-866-579-2678                           Facsimile: 604-875-4100 or 1-866-580-2678
E-mail: cmpt@interchange.ubc.ca
MycologyPlus Reponse Form
Laboratory Name CMPT Number Reponse Date Submitted by

KOH Preparation

Slide Number:
Staining Method: KOH:                  Calcofluor White:                Other:                       
Result: Positive:             Intermediate:                     Negative:                  
Comment:
KOH Preparation

Slide Number:
Staining Method: KOH:                  Calcofluor White:                Other:                       
Result: Positive:             Intermediate:                     Negative:                  
Comment:
 
Culture Preparation 1:
Preparation Number:
Media Used A B C
Incubation Temperature Medium A: Medium B: Medium C:
Days to Positive Result Medium A: Medium B: Medium C:
Result:
Comment:
  
Culture Preparation 2:
Preparation Number:
Media Used A B C
Incubation Temperature Medium A: Medium B: Medium C:
Days to Positive Result Medium A: Medium B: Medium C:
Result:
Comment:
 
Culture Preparation 3:
Preparation Number:
Media Used A B C
Incubation Temperature Medium A: Medium B: Medium C:
Days to Positive Result Medium A: Medium B: Medium C:
Result:
Comment:

Please note: This Print from Screen report form may be printed and used to submit results to CMPT via faxing completed forms to 604-875-4100. (This form may not print as a single page - it depends on your browser.)