Richmond-Prohaska v. Ethicon Inc et al, No. 2:2023cv00210 - Document 33 (W.D. Wash. 2023)
Court Description: ORDER granting Parties' 32 Joint MOTION FOR ENTRY OF AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL. Signed by Judge James L. Robart. (SS)
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Richmond-Prohaska v. Ethicon Inc et al Doc. 33 1 THE HONORABLE JAMES L. ROBART 2 3 4 5 6 IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WASHINGTON AT SEATTLE 7 8 9 DEBRA RICHMOND-PROHASKA, Case No. 2:23-CV-00210-JLR 10 Plaintiff, 11 vs. 12 13 ETHICON, INC., AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF Defendant. 14 15 16 Counsel for the parties having consented hereto, 17 IT IS on this 15th day of November, 2023, ORDERED that: 18 1. This protocol governs the preservation, collection, storage, and division of gross 19 and microscopic material purported to contain mesh or any other of Plaintiff’s tissue excised or 20 surgically explanted from Plaintiff at or near the site of mesh implantation, including but not 21 limited to slides, tissue/paraffin blocks, and gross material (the “Materials”). The Materials related 22 to explanted meshes are potentially unique and important evidence given the claims in cases 23 involving surgical mesh. 24 25 2. With one exception, nothing in this protocol directs healthcare facilities to deviate from normal procedures and policies regarding patient care, pathology processing and analysis, AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 1 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 Dockets.Justia.com 1 and specimen retention. The exception is where, in the normal course of business, any healthcare 2 facility would destroy explanted mesh or Materials. 3 Preservation and Collection 4 5 3. The Plaintiff will notify the health care facility that takes possession of the 6 explanted Materials at the time of the mesh removal that the Materials should be preserved and 7 that the Materials should be sent to Steelgate, Inc. 8 a. Where Plaintiff’s counsel learns of a Plaintiff’s potential revision/explant surgery 9 AFTER the date the surgery occurred, Plaintiff’s counsel must provide the agreed 10 upon Past Surgery preservation notice to the facility (attached as Exhibit A). 11 Ethicon’s attorneys must also be copied on this correspondence. 12 b. Where Plaintiff’s counsel learns of a Plaintiff’s potential revision/explant surgery 13 BEFORE the scheduled date of surgery, Plaintiff’s counsel must timely provide the 14 agreed upon Future Surgery preservation notice to the facility (attached as Exhibit 15 B). Ethicon’s attorneys must also to be copied on this correspondence. 16 4. Once a preservation notice has been sent, Steelgate, Inc. will arrange shipment of 17 the Materials to its facility in Florida. Steelgate will then act as a third-party repository of any 18 such Materials. 19 5. The parties will not interfere with the analysis and preservation of the Materials by 20 the explanting facilities to which any of the Plaintiff’s treating physicians have sent or will send 21 the Materials in the normal course of business. 22 6. Steelgate will timely notify Plaintiff and Defendant if and when the Materials are 23 requested from any facility and of obtaining the Materials. The written notification of receipt will 24 include the facility from which the Materials were received, an itemized inventory of the Materials 25 obtained (including collection date, type of specimen, and source site). Plaintiff will take all AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 2 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 1 and specimen retention. The exception is where, in the normal course of business, any healthcare 2 facility would destroy explanted mesh or Materials. 3 Preservation and Collection 4 5 3. The Plaintiff will notify the health care facility that takes possession of the 6 explanted Materials at the time of the mesh removal that the Materials should be preserved and 7 that the Materials should be sent to Steelgate, Inc. 8 a. Where Plaintiff’s counsel learns of a Plaintiff’s potential revision/explant surgery 9 AFTER the date the surgery occurred, Plaintiff’s counsel must provide the agreed 10 upon Past Surgery preservation notice to the facility (attached as Exhibit A). 11 Ethicon’s attorneys must also be copied on this correspondence. 12 b. Where Plaintiff’s counsel learns of a Plaintiff’s potential revision/explant surgery 13 BEFORE the scheduled date of surgery, Plaintiff’s counsel must timely provide the 14 agreed upon Future Surgery preservation notice to the facility (attached as Exhibit 15 B). Ethicon’s attorneys must also to be copied on this correspondence. 16 4. Once a preservation notice has been sent, Steelgate, Inc. will arrange shipment of 17 the Materials to its facility in Florida. Steelgate will then act as a third-party repository of any 18 such Materials. 19 5. The parties will not interfere with the analysis and preservation of the Materials by 20 the explanting facilities to which any of the Plaintiff’s treating physicians have sent or will send 21 the Materials in the normal course of business. 22 6. Steelgate will timely notify Plaintiff and Defendant if and when the Materials are 23 requested from any facility and of obtaining the Materials. The written notification of receipt will 24 include the facility from which the Materials were received, an itemized inventory of the Materials 25 obtained (including collection date, type of specimen, and source site). Plaintiff will take all AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 2 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 1 reasonable steps to ascertain collection dates and will notify Defendant immediately upon receipt 2 of this information. Plaintiff, Defendant, and Steelgate shall document the chain of custody for all 3 the Materials using the form attached as Exhibit C. 4 7. To the extent that the Materials have already been requested and/or are in 5 possession of Plaintiff or any of Plaintiff’s representative(s), within forty-five (45) days of the 6 entry of this Order Plaintiff will provide Defendant with an itemized inventory of the Materials 7 obtained (including collection date, type of specimen, source site, and a precise description of the 8 state of the materials encompassing fixation method (where applicable), a physical description 9 with the dimensions of any explanted material, color copies of any and all photographs of the 10 Materials, information regarding whether they have been altered in any fashion, an accounting of 11 what was received and what remains, etc.), and the name of the facility from which the materials 12 were obtained. Plaintiff will take reasonable steps to obtain collection date information and will 13 supplement information to Defendant upon receipt. Plaintiff will then, within sixty (60) days of 14 the entry of this Order, transfer such Materials for storage at Steelgate. 15 Storage 16 17 8. The Materials shall be preserved in a manner that permits the parties equal access 18 and analysis. The fixative used by the explanting health care facility shall be used while the 19 explanted Materials are stored at Steelgate. 20 9. The parties agree to split the expense of the monthly storage fees incurred by 21 storage of Materials at Steelgate. Following the division of Gross Specimens, each party shall bear 22 its own costs of continued storage of its share of the Materials at Steelgate, if any. 23 10. Prior to shipping any Materials, Gross Specimens, Slides, or any other pathology 24 to Plaintiff’s expert as contemplated in the sections “Division of Gross Specimens” and “Other 25 Pathology’ below, Plaintiff shall notify Defendant of her intention to ship said materials. Plaintiff AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 3 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 1 reasonable steps to ascertain collection dates and will notify Defendant immediately upon receipt 2 of this information. Plaintiff, Defendant, and Steelgate shall document the chain of custody for all 3 the Materials using the form attached as Exhibit C. 4 7. To the extent that the Materials have already been requested and/or are in 5 possession of Plaintiff or any of Plaintiff’s representative(s), within forty-five (45) days of the 6 entry of this Order Plaintiff will provide Defendant with an itemized inventory of the Materials 7 obtained (including collection date, type of specimen, source site, and a precise description of the 8 state of the materials encompassing fixation method (where applicable), a physical description 9 with the dimensions of any explanted material, color copies of any and all photographs of the 10 Materials, information regarding whether they have been altered in any fashion, an accounting of 11 what was received and what remains, etc.), and the name of the facility from which the materials 12 were obtained. Plaintiff will take reasonable steps to obtain collection date information and will 13 supplement information to Defendant upon receipt. Plaintiff will then, within sixty (60) days of 14 the entry of this Order, transfer such Materials for storage at Steelgate. 15 Storage 16 17 8. The Materials shall be preserved in a manner that permits the parties equal access 18 and analysis. The fixative used by the explanting health care facility shall be used while the 19 explanted Materials are stored at Steelgate. 20 9. The parties agree to split the expense of the monthly storage fees incurred by 21 storage of Materials at Steelgate. Following the division of Gross Specimens, each party shall bear 22 its own costs of continued storage of its share of the Materials at Steelgate, if any. 23 10. Prior to shipping any Materials, Gross Specimens, Slides, or any other pathology 24 to Plaintiff’s expert as contemplated in the sections “Division of Gross Specimens” and “Other 25 Pathology’ below, Plaintiff shall notify Defendant of her intention to ship said materials. Plaintiff AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 3 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 1 must provide the available information contained in Paragraphs 6 and 7 above prior to shipment. 2 Once provided this information, Defendant will have two (2) business days to alert the Plaintiff 3 prior to shipment of any need to meet and confer based on the state of the materials to be shipped. 4 In the event no agreement can be reached, the parties will seek the Court’s guidance. 5 Division of Gross Specimens 6 7 8 9 10 11 12 13 11. For the purposes of this section, “Gross Specimens” are preserved, explanted meshes and/or tissues that have not been processed into tissue/paraffin blocks or histology slides. 12. Each party is entitled to a representative one-half of any Gross Specimens in the exact form as received from the explanting healthcare facility. 13. Division of Gross Specimens will occur no later than sixty (60) days prior to the Plaintiff’s expert deadline. 14. Any division of Gross Specimens will be carried out by Plaintiff’s representative(s) 14 with the coordination and input of Defendant’s representative(s) to protect Defendant’s interest in 15 receiving a representative one-half of the Gross Specimen. 16 15. Defendant’s representatives will have the right to inspect the Gross Specimen and 17 obtain photographs and optical micrographs of the specimen prior to any alteration by or on behalf 18 of Plaintiff’s representative(s), and will have the right to observe, and provide input into, division 19 of the specimen into two comparable and approximately equal samples of mesh and tissue. 20 16. No tissue will be separated from mesh prior to dividing the Gross Specimen. 21 17. If the parties cannot agree regarding the manner of division of the Gross Specimen 22 or any portion thereof, the parties will meet and confer in good faith before any division takes 23 place. Neither party will perform any examination, analysis, or testing of the Gross Specimen in 24 any way prior to reaching mutual agreement. In the event no agreement can be reached, the parties 25 will seek the Court’s guidance. AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 4 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 1 a. If the amount of the preserved Gross Specimen is such that division in a manner 2 permitting analysis of the mesh and surrounding tissue by both parties is uncertain 3 upon receipt, the parties will meet and confer in good faith. No party will perform 4 any examination, analysis, or testing of the Gross Specimen or alter the Gross 5 Specimen in any way prior to reaching mutual agreement. In the event that no 6 agreement can be reached, the parties will seek the Court’s guidance. 7 b. If during the course of dividing the Gross Specimen to preserve at least one-half for 8 use by Defendant, the impossibility of providing Defendant with the Gross 9 Specimen useable in the same manner as that intended by the Plaintiff becomes 10 apparent, the parties will likewise meet and confer in a good faith effort and, if 11 necessary, seek the Court’s guidance. Neither party will perform any examination, 12 analysis, or testing of the Gross Specimen or alter the Gross Specimen in any way 13 prior to reaching mutual agreement protocol. 14 18. Following the division of any Gross Specimen into halves that are agreed upon by 15 the parties’ representatives present at the division of the Gross Specimen, the parties are free to 16 conduct any testing or analysis on their halves, including destructive testing. 17 Other Pathology 18 19 19. Upon receipt, Steelgate will maintain any tissue/paraffin blocks or slides obtained 20 from pathology (“the Slides”) in an appropriate manner that effectively preserves them for 21 examination and testing by both parties. 22 23 a. The tissue/paraffin blocks and/or slides will be stored and maintained by Steelgate until requested by either party. 24 25 AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 5 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 C 1 b. No later than three (3) months prior to the Plaintiff’s expert deadline, the parties 2 will meet and confer regarding retrieval from Steelgate of the tissue/paraffin blocks 3 and/or slides related to the Plaintiff. 4 c. The apportionment and trading of tissue/paraffin blocks and/or slides will follow 5 the procedure discussed in Paragraph 20 of this protocol. The parties will meet and 6 confer regarding the Plaintiff’s selection of a representative who will be responsible 7 for creating pathology slides from the tissue/paraffin blocks and the procedure for 8 creating such recuts. In the event that no agreement can be reached, the parties will 9 seek the Court’s guidance. 10 d. Pathology slides will be created from the tissue/paraffin blocks using standard 11 operating procedures, by or under the direction of the representative selected 12 according to Paragraph 19(c). 13 20. To the extent that any facility will not release tissue/paraffin blocks and/or slides to 14 Steelgate absent a court order, and to extent either party seeks to request any facility cut additional 15 slides from any tissue/paraffin block for use by their expert(s), the requesting party will ensure that 16 the tissue/paraffin block contains sufficient material to create an equal number of slides for each 17 party. Prior to requesting such slides, the requesting party shall notify the other side and meet and 18 confer regarding the number of slides to be requested and whether the slides will be stained or 19 unstained. The parties will work to complete the meet and confer process such that the slides can 20 be requested from the facility within seven (7) days of the requesting party’s notification. Plaintiff 21 will timely provide Defendant the Slides (including originals and recuts) following Plaintiff’s 22 expert(s) review. Defendant will likewise provide Plaintiff any recuts reviewed by Defendant’s 23 expert(s). 24 25 AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 6 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 1 21. This Order specifically authorizes any facility in possession of any Materials 2 relating to the Plaintiff to provide the Materials to Steelgate when requested, assuming Healthcare 3 Insurance Portability and Accountability Act requirements are otherwise satisfied. 4 This Order does not modify any of the Plaintiff’s pre-existing preservation obligations. 5 6 7 8 9 ENTERED: November 15, 2023 A __________________________________________ JAMES L. ROBART UNITED STATES DISTRICT JUDGE 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 AGREED ORDER AND STIPULATION REGARDING PATHOLOGY PROTOCOL FOR PRESERVATION AND TESTING OF EXPLANTS AND TISSUE SAMPLES TAKEN FROM PLAINTIFF (Case No. 2:23-CV-00210-JLR) - 7 LAW OFFICES MORGAN, LEWIS, & BOCKIUS LLP 1301 SECOND AVENUE, SUITE 2800 SEATTLE, WASHINGTON 98101-3808 TEL (206) 274-6400 FAX (206) 407-2224 EXHIBIT “A” NOTICE TO PRESERVE EVIDENCE URGENT ACTION REQUIRED [Date] Attn: Department of Pathology [Address of Facility] Re: [Date of Surgery, Case Caption] Dear Department of Pathology: I represent the Plaintiff, [PLAINTIFF FIRST, MIDDLE, LAST NAME], and , copied below, represents the Defendant, Ethicon, Inc. (Ethicon), in the above-referenced lawsuit. There is no litigation pending against your facility or the treating physician in this matter. The pathology and any explanted mesh material is important evidence in pending litigation against Ethicon and preservation of these items is critical. I write to request the following: • Please verify if any pathology and explant material is available from [FIRST, MIDDLE, LAST NAME]’s [date] surgery performed by Dr. [Explant Surgeon], if so, please continue to preserve using your standard method of preserving pathology and/or explant materials. • If a specimen or explant material is available, the parties further request that you contact our explant pathology storage facility representative to arrange for the shipment and storage of these preserved materials once your normal pathology procedures have been completed. Standard delivery FedEx or UPS shipping is sufficient to: Kate Grayson Steelgate, Inc., 2307 58th Avenue East Bradenton, Florida 34203 kate@steelgateinc.com (941) 758-1122 or (866) 647-8335 To facilitate this request, enclosed please find a HIPAA-compliant authorization signed by the above-referenced Plaintiff for the release of the pathology and explant specimens to Steelgate as instructed above. Instructions for Reimbursement for Costs Incurred: For reimbursement of costs incurred in the collection, preservation, and shipping of the specimens, please submit an itemized invoice to: [PLAINTIFF’S COUNSEL, FIRM NAME, ADDRESS, PHONE/EMAIL] Should you have any questions or concerns regarding this matter, please contact either Ms. Grayson or the undersigned. If you are not the appropriate recipient of this request, please notify and forward a copy of this letter to the appropriate person or entity responsible for ensuring compliance with the terms of this request at your earliest convenience. Thank you very much for your assistance. Very truly yours, [Signature Block: Counsel for Plaintiff] Encls. as stated cc: [Defense counsel (email)] Kate Grayson (kate@steelgateinc.com) 2 EXHIBIT “B” NOTICE TO PRESERVE EVIDENCE URGENT ACTION REQUIRED [Date] Attn: Department of Surgery and Pathology [Address of Explant Facility] Re: [Date of Anticipated Explant Surgery, Case Caption] Dear Department of Surgery and Pathology: I represent the Plaintiff, [PLAINTIFF FIRST, MIDDLE, LAST NAME], and , copied below, represents the Defendant, Ethicon, Inc. (Ethicon), in the above-referenced lawsuit. There is no litigation pending against your facility or the treating physician in this matter. The pathology and any remaining explanted mesh material is important evidence in pending litigation against Ethicon and preservation of these items is critical. I write to request the following: • Please follow the pathology procedures your facility uses in the ordinary course of business. Once you have completed your normal pathology procedures, we request that any pathology, paraffin blocks, and/or pathology slides, as well as any tissues and/or the explanted mesh obtained during [PLAINTIFF FIRST, MIDDLE, LAST NAME]’s upcoming surgery, should be preserved by using your standard operating procedures for preserving pathology and explant materials. Remaining gross specimens containing mesh and/or tissue should be placed in a container of dilute formalin (10% is standard). All pathology described above should then be shipped to our storage facility, at our expense, as discussed below. • [PLAINTIFF FIRST, MIDDLE, LAST NAME]’s surgery is scheduled for [date], to be performed by Dr. [Explant Surgeon]. • Please contact our explant pathology storage facility representative to arrange for the shipment and storage of these materials. Contact information is as follows: 3 Kate Grayson Steelgate, Inc., 2307 58th Avenue East Bradenton, Florida 34203 kate@steelgateinc.com (941) 758-1122 or (866) 647-8335 To facilitate this request, enclosed please find a HIPAA-compliant authorization signed by the Plaintiff for the release of the pathology and explant specimens to Steelgate as instructed above. Instructions for Reimbursement for Costs Incurred: For reimbursement of costs incurred in the collection, preservation, and shipping of the specimens, please submit an itemized invoice to: [PLAINTIFF’S COUNSEL, FIRM NAME, ADDRESS, PHONE/EMAIL] Should you have any questions or concerns regarding this matter, please contact either Ms. Grayson or the undersigned. If you are not the appropriate recipient of this request, please notify and forward a copy of this letter to the appropriate person or entity responsible for ensuring compliance with the terms of this request at your earliest convenience. Thank you very much for your assistance. Very truly yours, [Signature Block: Counsel for Plaintiff] Encls. as stated cc: [Defense counsel (email)] Kate Grayson (kate@steelgateinc.com) 4 EXHIBIT "C" CHAIN OF CUSTODY FORM FOR PATHOLOGY MATERIALS Patient Name: _______________________________ Date: ______________________________________ Law Firm: __________________________________ Surgery Date: ________________________________ ENTRY NO. 1: Pick Up Location / Releasing Party Information: Facility Name: Address: _______________________________________________________________________________ Address: _______________________________________________________________________________ Contact Name: ___________________________________ Department: ___________________________ Contact Phone #: Contact Email:________________________________ Item Description (include manner of preservation, size of specimen, slide number and any other identifying mark(s)). (1) ___________________________________________ (2) _____________________________________ (3) ___________________________________________ (4) _____________________________________ Person RELEASING Shipment: _________________________________________________________ (sign/print) Date: ____________________________ Time: ________________ Witness: ____________________________________________________________________________ (sign/print) Date: ____________________________ Time: _______________ ENTRY NO. 1: Recipient Location/Receipt information: Facility Name: Steelgate Inc., 2307 58th Avenue East, Bradenton, FL 34203 Item Description (include manner of preservation, size of specimen, slide number and any other identifying mark(s)). (1) ___________________________________________ (2) _____________________________________ (3) ___________________________________________ (4) _____________________________________ Note any changes of condition: Condition of specimen: ambient (__), frozen (__), unfrozen (__), refrigerated (__) Condition of Container: undamaged (__), damaged (__), describe:_______________________________ Person RECEIVING Shipment: _________________________________________________________ (sign/print) Date: ____________________________ Time: _______________ Witness: ____________________________________________________________________________ (sign/print) Date: ____________________________ Time: _______________ Page 1 of 3 CHAIN OF CUSTODY FORM FOR PATHOLOGY MATERIALS Patient Name: _____________________________ Date: _____________________________________ Law Firm: _________________________________ Surgery Date: ______________________________ ENTRY NO. 2: Pick Up Location / Releasing Party Information Facility Name: Steelgate Inc., 2307 58th Avenue East, Bradenton, FL 34203 Item Description (include manner of preservation, size of specimen, slide number and any other identifying mark(s). (1) ____________________________________________(2) _____________________________________ (3) ___________________________________________(4) _____________________________________ Person RELEASING Shipment: ______________________________________________________ (sign/print) Date: ____________________________ Time: _________________ Witness: ____________________________________________________________________________ (sign/print) Date: ____________________________ Time: _________________ ENTRY NO. 2: Recipient Location/Receipt information: Facility Name: Address: ____________________________________________________________________________ Address: ____________________________________________________________________________ Contact Name: ___________________________________ Department __________________________ Contact Phone #: ___________________Contact Email: _____________________________________ (1) ____________________________________________(2) _____________________________________ (3) ___________________________________________(4) _____________________________________ Note any changes of condition: Condition of specimen: ambient (__), frozen (__), unfrozen (__), refrigerated (__) Condition of Container: undamaged (__), damaged (__), describe: ______________________________ Person RECEIVING Shipment: _________________________________________________________ (sign/print) Date: _____________________________Time: ________________ Witness: _____________________________________________________________________________ (sign/print) Date: ____________________________ Time: _________________ Page 2 of 3 CHAIN OF CUSTODY FORM FOR PATHOLOGY MATERIALS Patient Name: ______________________________ Date: _____________________________________ Law Firm: __________________________________ Surgery Date: ______________________________ ENTRY NO. 3: Pick Up Location / Releasing Party Information Facility Name: Item Description (include manner of preservation, size of specimen, slide number and any other identifying mark(s). (1) ____________________________________________ (2) _____________________________________ (3) ___________________________________________ (4) _____________________________________ Person RELEASING Shipment: _________________________________________________________ (sign/print) Date: ___________________________ Time: _________________ Witness: ____________________________________________________________________________ (sign/print) Date: ___________________________ Time: _________________ ENTRY NO.3: Recipient Location/Receipt information: Facility Name: Address: Address: ___________________________________________________________________________ Contact Name: __________________________________ Department __________________________ Contact Phone #: Contact Email: Item Description (include manner of preservation, size of specimen, slide number and any other identifying mark(s). (1) ____________________________________________ (2) _____________________________________ (3) ___________________________________________ (4) _____________________________________ Note any changes of condition: Condition of specimen: ambient (__), frozen (__), unfrozen (__), refrigerated (__) Condition of Container: undamaged (__), damaged (__), describe: _____________________________ Person RECEIVING Shipment: _________________________________________________________ (sign/print) Date: ___________________________ Time: _________________ Witness: ___________________________________________________________________________ (sign/print) Date: ___________________________ Time: _________________ Page 3 of 3
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