Commonwealth 0£ Virginia
Department of General Services
Division 0£ Conso1idated Laboratory Services
600 N. 5t:b. Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS
TO :

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261-6963

Date Received:

10/26/2016

Samp1e Description

Two sealed containers were received. Container #1 was 250 mL of 2 mEq/mL
potassium chloride, lot 531 htrnpn - per 234. Container #2 was 10 mL of 5 mg/mL
rnidazolam, lot 531 htmpn - par 234.
Teat Requested: Verification of labeled concentration for each container
Test Results (Chemical) :

The following concentrations were determined for each submitted sample.
Containe~ #1 2.11 + 0.006 mEq/mL Chlorine
1.79 + 0.005 mEq/mL Potassium
Container #2 -

4.47 + 0.77 mg/mL midazolam

Date Reported:

11/9/2016

ATTEST:

I/We certify that I/We performed the above analysis or exaulination as an employee of and

in a laboratory operated by the Division of Consolidated Laboratory Services and that the

above is an accurate record of the results of that analysis or examination.

\\
Analyst Signature
Analyst Name (Pr "nt)

Date

Analyst Signature

Date

Analyst Name (Print)

Page 1 of 1

 Commonwea1th of Virginia
Department of Generai Services
Division of Conso1idated Laborato.ry Services
600 N. 5~ Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS

AMENDED
TO:

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261-6963
Date Received:

10/26/2016

Sample Description
Two sealed containers were received.
Container #1 was 250 mL of 2 mEq/mL
potassium chloride, lot 531 htrnpn - per 234.
Container #2 was 10 mL of 5 mg/mL
midazolam, lot 531 htmpn - par 234.

Test Requested: Verification of labeled concentration for each container
Test Results (Chemical):
The following concentrations were determined for each submitted sample.
Container #1 1.79 + 0.005 mEq/mL Chlorine*
2.11 + 0.006 mEq/mL Potassium*
Container #2 -

4.47 + 0.77 mg/mL midazolam

*This is an amended resuit for Container #1.
The originai Certificate of
Ana1ysis, issued 11/9/2016, 1isted the resu1ts for potassium and ch1orine in
reverse order.
Date Reported:

12/16/2016

ATTEST:

I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or examination .

.,<~~Ac-= ~~r:::=

Analyst si9'lla~re

Analyst Name (Print) ~

l1-£.ate{
l {, /';o\ b

Analyst Signature

Date

Analyst Name (Print)

Page 1 of 1

 Commonwealth of Virginia
Depart.ment of General Services
Division of Consolidated Laboratory Services
600 N. 5th Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS

AMENDED#2*
TO:

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261-6963
Date Received:

10/26/2016

Sample Description
Two sealed containers were received and labeled as follows: Container #1
was 250 mL of 2 mEq/mL potassium chloride, lot 531 htrnpn - per 234. Container
#2 was 10 mL of 5 mg/mL midazolam, lot 531 htrnpn - par 234.
Test Requested: Verification of labeled concentration for each container
Test Results (Chemical):
The following concentrations were determined for each submitted sample.
Container #1 1.97 + 0.006** mEq/mL Chloride
1.91 + 0.020** mEq/mL Potassium

Container #2 -

4.47 + 0.77** mg/mL midazolam

Page

1

*This is an amended Certificate of Analysis. The reported concentrations of potassium and chloride have been updated. The
measurement of uncertainty for potassium has been updated. Previous Certificates of Analysis were issued on 11/9/2016 and
12/16/2016.
**Values represent analyte concentration± the measurement of uncertainty as determined by method validation.

of 2

 Commonwea.1 th of Virginia

DepartmeJlt of Gener•l Services
Division of Conso.lidated Laboratory Services
600 N. 5~ Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS

AMENDED#2
Date Reported:

12/21/2016

ATTEST:

I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the

above is an accurate record of the results of that analysis or examination.

7:JµMfil, ~ ttf 1(I1;~
alyst Signature

Dat

Date

Analyst Name (Print)

ltst !!&aee

1~12.l /f~
D te

Analyst Signature

Date

S~e. ·W10\-\-.\-

Analyst Name (Print)

Analyst Name (Print)

Page 2 of 2

 Cammonwea1th of Virginia
Department of Generai Services
Division of Conso1idated Laboratory Services
600 N. 5~ Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS

AMENDED*
TO:

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261-6963
Date Received:

Samp1e Description
Four sealed containers
• Container #1 was
- per 234
Container
#2 was
•
- per 234
• Container #3 was
• Container #4 was

12/5/2016

were received and labeled as follows:
250 mL of 2 mEq/mL potassium chloride, lot 531 htrnpn
250 mL of 2 mEq/mL potassium chloride, lot 531 hhpeho
10 mL of 5 mg/mL midazolam, lot 531 htrnpn - par 234
10 mL of 5 mg/mL midazolam, lot 531 hhpeho - par 234

Test Requested: Verification of labeled concentration for each container
Test Results (Chemical):
The following concentrations were determined for each submitted sample.
Container #1 1.98 + 0.006** mEq/mL Chloride
2.05 + 0.020** mEq/mL Potassium

Container #2 -

1. 99 -+ 0.006** mEq/mL Chloride

2.08 + 0.020** mEq/mL Potassium
-

Container #3 -

5.07 -+ 0.77** mg/mL midazolam

Container #4 -

5.00 + 0.77** mg/mL midazolam
-

Page 1 of 2
*This is an amended Certificate of Analysis. The reported concentrations of potassium and chloride have been updated. The
measurement of uncertainty for potassium has been updated. Previous Certificates of Analysis were issued on l l/9/2016 and
12/16/2016.
**Values represent analyte concentration± the measurement of uncertainty as determined by method validation.

 Cammonwea.lth of Virginia
Department of Genera.l Services
Division of Conso.lidated Laboratozy Services
600 N. 5th Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS

Amended
Date Reported:

12/21/2016

ATTEST:
I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or examination.

~~
MicheJk Kauer-

Analyst Name (Print)

.1.---

~ ,,_.,--

12 )21/1&,
nli.te /

Date

Analyst Namerint)

AriaiYSt Signature

Analyst Signature

Analyst Name (Pr nt)

Analyst Name (Print)

Date

Page 2 of 2

 Commonwea1th of Virginia
Department of Generai Services
Division of Conso1idated Laboratozy Services
600 N. 5~ Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS
TO:

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261-6963
Date Received:

12/5/2016

Sample Description
Four sealed containers were received.
• Container #1 was 250 mL of 2 mEq/mL potassium chloride, lot 531 htrnpn
- per 234
• Container #2 was 250 mL of 2 mEq/mL potassium chloride, lot 531 hhpeho
- pcr234
• Container #3 was 10 mL of 5 mg/mL midazolam, lot 531 htrnpn - par 234
• Container #4 was 10 mL of 5 mg/mL midazolam, lot 531 hhpeho - par 234
Test Requested: Verification of labeled concentration for each container
Test Results (Chemical) :
The following concentrations were determined for each submitted sample.
Container #1 1.98 + 0.006 mEq/mL Chlorine
2.05 + 0.005 mEq/mL Potassium
Container #2 -

2.00 + 0.006 mEq/mL Chlorine
2.08 + 0.005 mEq/mL Potassium

Container #3 -

5.07 + 0.77 mg/mL midazolam

Container #4 -

5.00 + 0.77 mg/mL midazolam
-

Date Reported:

12/12/2016

ATTEST!

I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or examination.

JJ'- tv~

Analyst sigTI.ature

Analyst Name (Print)

D te

Analyst Signature

Date

Analyst Name (Print}

Paqe 1 of 1

 Commonwealth of Virginia
Department of General Services
Division of Conso1idated Laboratory Services
600 N. 5th Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS
TO:

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261-6963

Date Received:

10/26/2016

Sample Description
Two sealed containers were received.
Container #1 was 250 mL of 2 mEq/mL
potassium chloride, lot 531 htrnpn - per 234.
Container #2 was 10 mL of 5 mg/mL
rnidazolam, lot 531 htmpn - par 234.
Test Requested: Verification of labeled concentration for each container
Test Results (Chemical) :
The following concentrations were determined for each submitted sample.
Container #1 2.11 + 0.006 mEq/mL Chlorine
1.79 + 0.005 mEq/mL Potassium
Container #2 -

4.47 + 0.77 mg/mL midazolam

Date Reported:

11/9/2016

ATTEST:
I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or examination.

Analyst Signature

Analyst Name (Print)

'

1

Date

Analyst Signature

Date

Analyst Name (Print)

Page 1 of 1

 Commonwealth of Virginia
D-.Partment of General Services
Division of Consolidated Laboratory Services
600 N. 5 th Street
Richmond, ~ 23219
(804) 648-4480

CERTIFICATE OF ANALYSIS
TO :

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261 - 6963
Date Received:

1/6/2017

Sample Description

Four sealed containers
• Container #1 wa s
- per 234
Container
#2 was
•
- per 234
• Container #3 was
• Container #4 was

were received and labeled as follows :
25 0 mL of 2 mEq /mr. p otassj 11m c h l o ri de , Jot 53 1 htrnpn
250 mL of 2 mEq/mL potassium chloride, lot 531 hhpeho
10 mL of 5 mg/mL midazolam, lot 531 htrnpn - par 234
10 mL of 5 mg/mL midazolam, lot 531 hhpeho - par 234

Test Requested: Verification of labeled concentration for each container
Te.t a..ults (Chemical);

The following concentrations were determined for each submitted sample .
2.00 + 0.006 mEq/mL Chloride
Container #1 2.00 ± 0.020 mEq/mL Potassium
Container #2 -

2.03 ± 0.006 mEq/mL Chloride
2.00 + 0.020 mEq/mL Potassium

Container #3 -

4 . 80

Container #4 -

5.14 ± 0.77 mg/mL midazolam

± 0.77 mg/mL midazolam

Page 1 of 2

 Commonve~lth of Virginia
.oepart..nt of GelHtral Services
Division of Consolidated Laboratory Services
600 N. 5~ Street
Richmond, VA 23219

(804)

648-4480

CERTIFICATE OF ANALYSIS

Date Reported:

1/12/2017

ATTEST:
l/We certify that l/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or examination.

Analyst Signature

l/-Jjj[l
Analyst Name (Print)

1/11./r7
Da te

~:y Arm1ti~~

Analyst Name (

int)

Analyst Signature

Date

Analyst Name (Print)

Paqe 2 of 2

 •

L . -_ _ _. . . . . ; ; ; . _

c:::_____ •

Attachment V

or Virginia
Genera~ Services
Division or Conso~idated Laboratory Services
600 N. S~ Street
Richmond, VA 23219
Commonwea~th

~artment

or

(804)

648-4480

CERTIFICATE OF ANALYSIS
TO:

Cookie Scott
Department of Corrections
P.o. Box 26963
Richmond, VA 23261-6963
Date Received:

sample Description
Four sealed containers
• Container #1 was
- pcr 234
• Container #2 was
- pcr 234
• Container #3 was
• Container #4 was

2/3/2017

were received and labeled as follows:
250 mL of 2 mEg/mL potassium chloride, Jot 531 htrnpn
250 mL of 2 mEq/mL potassium chloride, lot 531 hhpeho
10 mL of 5 mg/mL midazolam, lot 531 htrnpn - par 234
10 mL of 5 mg/mL midazolam, lot 531 hhpeho - par 234

Test Requested: Verification . of labeled concentration for each container
Test Results (Chemical) :
The following concentrations were determined for each submitted sample.
Container #1 2.04 -+ 0.006 mEq/mL Chloride
1. 99 -+ 0.020 mEq/mL Potassium
Container #2 -

2.03
2.00

Container #3 -

4.12 -+ 0.77 rng/mL midazolarn

Container #4 -

4.10 -+ 0.77 mg/mL midazolam

0.006 mEq/mL Chloride
-+
-+ 0.020 mEq/rnL Potassium

Page 1 of 2

 COllllllOnwea~th or Virginia
Department or Genera~ Services
Division or Conso~idated Laboratory Services
600 N. 5~ Street
Richmond, v.A 23219

(804)

648-4480

CERTIFICATE OF ANALYSIS

Date Reported:

2/22/2017

ATTEST:

I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or examination.

,

Analyst Signature

Da?e

~ClM~
st Si~e

I
f
;(1~'1
Date

An~lyst Name < rint)

jUiCIdL
71((}(W(
Analyst Signature
Analyst Name (Print)

Analyst Signature

Date

Analyst Name (Print)

Page 2 of 2

 Commonwealth of Virginia

Department of Genera I Services
Division of Consolidated

(C1Cl
~ \\ lllEID)
1.& a \!I

L~b.o~atory serviC
'"~I

R chmond, VIrginIa

11 .lJ;;;1

APR 1.1 .2017
Oeputy Director, Administration
Commonwealth of Virginia
Department of General Services
Division of Consolidated Laboratory Services
600 N . 5 th Street

Ilichmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS
TO :

Cookie Scott
Department of Corrections
P.O. Box 26963
Richmond, VA 23261-6963
Date Received:

Sample Description
Four sealed containers
Container #1 was
- per 234
Container
#2 was
•
- pcr 234
• Container #3 was
Container #4 was

•

3/13/20 1 7

were received and labeled as follows:
250 mL of 2 mEq/mL potassium chloride, lot 531 htrnpn
250 mL of 2 mEq/mL potassium chloride, lot 531 hhpeho
10 mL of 5 mg/mL midazolam,
10 mL of 5 mg/mL midazolam,

lot 531 htrnpn - par 234
lot 531 hhpeho - par 234

Test Requested: Verification of labeled concentration for each container
Test Results (Chemical):
The following concentrations were determined for each submitted sample.
Container #1 -

2.01 + 0.006 mEq/mL Chloride
1. 90 + 0.020 mEq/mL Potassium
-

Container #2 -

1. 99 + 0 . 006 mEq/mL Chloride
1. 93 + 0.020 mEq/mL Potassium

container #3 -

4.47 + 0.77 mg/mL midazolam

Container #4 -

4.65 -+ 0.77 mg/mL midazolam

-

Page 1 of 2

Document #: 19644
Revision: 1
Date Publ ished : 03/29/17
Issuing Authority: Group Manager

Page 1 of 2

 Commonwea~th or Virginia
Department or Genera~ Services
Division or Conso~idated Laboratory Services
600 N. 5 th Street
Richmond, VA 23219

(804)

648-4480

CERTIFICATE OF ANALYSIS

Date Reported:

4/5/2017

ATTEST:

I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or examination.

~ bJ~

Analyst Si~ --

Analyst Name

'-II ~/l1V Date

MiclatJ LR MOI1e.r

Analyst Name (Print)

(Pr~nt)

Date

Analyst Signature

Date

Analyst Name (Print)

Page 2 of 2
Title: DOC Certificate of Analysis Template
Document #:19644
Revision: 1
Date Published: 03/29/17
Issuing Authority: Group Manager

Page 2 of 2

 Commonwealth of Virginia
Department of Genera I Services

Division of Consolidated Laboratory Services
Richmond , Virginia

Commonwea~th

Division of

of Virginia

Services
Laboratory Services
600 N. sth Street
Richmond, VA 23219

Department of

Genera~

Conso~idated

(804)

648-4480

CERTIFICATE OF ANALYSIS

TO :

Cookie Scott
Department of Corrections
P . O . Box 26963
Richmond, VA 23261-6963
Date Received:

4 /7/2017

Sample Description
Four sealed containers were received and labeled as follows :
• Container #1 was 250 mL of 2 mEq/mL potassium chloride , lot
- pcr 234 (Label has projected expiration date o f 2/28/2017)
• Container #2 was 250 mL of 2 mEq/mL potassium chloride, lot
- pcr 234
• Container #3 was 10 mL of 5 mg / mL midazolam, l ot 531 htrnpn
(Label has projected expiration date of 4 /1/2017)
Container #4 was 10 mL of 5 mg/mL midazolam, lot 531 hhpeho

531 htrnpn
531 hhpeho
- par 234
- par 234

Test Requested : Ve rification of labeled concentration for each container
Test Results (Chemical):
The follow ing concentrations were determined for each submitted sampl e.
Container #1 -

1. 99 + 0.006 mEq/mL Chl oride
1. 92 + 0.020 mEq/mL Potassium

Containe r #2 -

2.01 + 0 . 006 mEq/mL Chlor i de
1. 94 .:': 0.020 mEq/mL Potassium

Conta iner #3 -

5.25 + 0.52 mg/mL mida zolam
-

-

4 . 69 -+ 0 . 52 mg/mL midazolam

Conta iner #4

Page 1 of 2
Document # :19644
Revision: 1

Date Published : 03/29/17
Issuing Authority: Group Manager

Page 1 of 2

 Commonwea~th of Virginia
Department or General Services
Division of Conso~idated Laboratory Services
600 N . 5 '" Street
Richmond, VA 23219

( 8 04 )

648 - 448 0

CERTIFICATE OF ANALYSIS

Date Reported:

4/28/2017

ATTEST :
I /we certify that I/We performed the above analysis o r examination as an employee of and

in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is a n accurate r ecord of the results o f that analysis or examination .

~

OJfr=:

Analyst Signature

Analyst Name (Print)

---)Ut'rJd17tjf)(.{LA sjLfU:r
Analyst Signature

Analyst Name

(Print )

Analyst Signatur e

;:r,,'l Armst rDY1J

Analyst Name

Date

Date

(Print)

Page 2 of 2
Title: DOC Certificate of Analysis Template
Docume nt # :19644

Revis ion: 1
Date Published: 03/29/ 17

Issuing Auth ority: Group Manager

Page 2 of 2

 Commonwealth of V irginia
Department of General Services
Division of Consolidated Laboratory Services
Richmond, V irgin ia

Commonwea~tb of Virginia
Department of Genera~ Services
Divi sion of Conso~idated Laboratory Services
600 N . 5 ~ Street
Richmond, VA 23219

(804)

648- 4 48 0

CERTIFICATE OF ANALYSIS
TO:

Cookie Scott
Department of Correct ions
P . O. Box 26963
Richmond, VA 23261-6963
Date Received :

5/11 /2017

Sample Description
Six sealed containers were received and labeled as follows:
• Container #1 was 250 mL of 2 mEq /mL potassium chloride, lot 531 htrnpn - pcr
234 (Label has projected expiration date of 2/28/2017)
• Container #2 was 250 mL of 2 mEq/mL pot assium chloride, lot 531 hhpeho - pcr
234 (Label has a projected expiration date of 5/1/2017)
•

Container #3 was 250 mL of 2 mEq/mL potassium chloride,

lot 531 pmhths - per

234
•

Container #4 was 10 mL of 5 mg/mL midazolam,

•

has projected expiration date of 4 / 1 / 201 7)
Container #5 was 10 mL of 5 mg/mL midazolam, lot 531 hhpeho - par 234 (Label
has projected expiration date of 5/1/2017)

lot 531 htrnpn - par 234

•

Container #6 was 10 mL of 5 mg/mL midazolam,

lot 531 pmhths - par 234

Test Requested: Verification of labeled concentration for each container
Test Results (Chemical) :
The following concentrations were determined for each submitted sample .
Cont a iner #1 -

Container #2

-

1. 97 + 0 . 006 mEq/mL Chloride
1. 93 + 0.020 mEq/mL Potassium

2 . 00 + 0.006 mEq/mL Chloride
1. 95 + 0 . 020 mEq/mL Potassium

Container #3

-

2.00

~

0 .006 mEq/mL Chloride

1. 94 + 0.020 mEq/mL Potassium

Container #4 Conta i ner #5 Container #6 -

4 . 29 ~ 0.52 mg/mL midazolam
3.89 + 0.52 mg/mL midazolam
4.64 + 0.52 mg/mL midazolam

Document #:19644
Revision: 1

Date Published: 03/29/17
Iss uing Authority: Group Ma nage r

Page1of2

(Label

 Page 1 of 2

Commonwea~th of Virginia
Department of Genera~ Services
Division of Conso~idated Laboratory Services
600 N. sth Street
Richmond, VA 23219
(804)

648-4480

CERTIFICATE OF ANALYSIS

Date Reported:

6/8/2 0 1 7

ATTEST:
I/We certify that I/We performed the above analysis or examination as an employee of and
in a laboratory operated by the Division of Consolidated Laboratory Services and that the
above is an accurate record of the results of that analysis or exam.i nation .

Analyst Signature

, .Date

Analyst Name (P lnt)

'l« 'cJ;.d£.~
Analyst Signature

Analyst Name (Print)

~st signatJre

ft If/
J7
Date

alyst Namerint)

~(q

bE-

Date

Analyst Signature

Date

Ana l yst Name (Print)

Page 2 of 2
T itle: DOC Certificate of Analysis Template
Document #: 19644
Revision : 1
Date Published: 03/29/17
Issuing Authority: Group Manager

Page 2 of 2