+--------------------------------------------+-------------------------+
| ![](medi                                   |                         |
| a/image1.png){width="1.3902777777777777in" |                         |
| height="0.7201388888888889in"}ATTACHMENT   |                         |
| 1: M&TE Report                             |                         |
+--------------------------------------------+-------------------------+
| **5006-1**                                 | Records Use only        |
|                                            |                         |
| **M&TE Report**                            |                         |
+--------------------------------------------+-------------------------+
| **Section I (M&TE Coordinator completes)** |                         |
+--------------------------------------------+-------------------------+
| 1\. M&TE identifier:       2. Description: |                         |
|       3. Location:                         |                         |
|                                            |                         |
| 4\. Capacity/range:       5. Tolerance     |                         |
| required:       6. Calibration frequency:  |                         |
|                                            |                         |
|                                            |                         |
| 7\. Special handling, storage,             |                         |
| maintenance, instructions:                 |                         |
|                                            |                         |
| 8\. Assigned coordinator:                  |                         |
|                                            |                         |
| (print name)                               |                         |
|                                            |                         |
| 9\. A nationally recognized reference      |                         |
| standard does not exist; the basis for     |                         |
| calibration is as follows:                 |                         |
|                                            |                         |
| 10\. The accuracy of the reference         |                         |
| standard equals the required calibration   |                         |
| tolerance, and the basis for the           |                         |
| calibration is as follows:                 |                         |
+--------------------------------------------+-------------------------+
| Note: M&TE Coordinator signature only      |                         |
| required when entering M&TE into the EP    |                         |
| M&TE database or for subsequent changes to |                         |
| the information in Section I.              |                         |
|                                            |                         |
| 11\. M&TE Coordinator: [     ]{.underline} |                         |
| [     ]{.underline}                        |                         |
|                                            |                         |
| Print name and Title/Signature Date        |                         |
+--------------------------------------------+-------------------------+
| **Section II (Calibrator completes, or     |                         |
| information is provided on separate, but   |                         |
| comparable, attached documentation)**      |                         |
+--------------------------------------------+-------------------------+
| 12\. Calibration procedure/revision no.:   |                         |
|       13. Reference standard identifier:   |                         |
|       14. Reference standard description:  |                         |
|                                            |                         |
|                                            |                         |
| 15\. Reference standard accuracy:          |                         |
| 16. Accuracy before calibration:       17. |                         |
| Accuracy after calibration:                |                         |
|                                            |                         |
| 18\. M&TE within tolerance before          |                         |
| calibration M&TE calibrated within the     |                         |
| specified tolerance                        |                         |
|                                            |                         |
| M&TE not within tolerance before           |                         |
| calibration M&TE could not be calibrated   |                         |
| within the specified tolerance             |                         |
|                                            |                         |
| 19\. Calibrator: [                         |                         |
| \_\_\_\_\_\_\_\_\_]{.underline}            |                         |
| [     ]{.underline}                        |                         |
|                                            |                         |
| Print name and Title/Signature Date        |                         |
+--------------------------------------------+-------------------------+
| **Section III (M&TE Coordinator            |                         |
| completes)**                               |                         |
+--------------------------------------------+-------------------------+
| 20\. Calibration status:                   |                         |
|                                            |                         |
| > M&TE calibration checked and within      |                         |
| > tolerance M&TE removed from the EP M&TE  |                         |
| > database this date:                      |                         |
| >                                          |                         |
| > M&TE not used since last calibration     |                         |
| > M&TE not within tolerance before         |                         |
| > calibration---not used since last valid  |                         |
| > calibration                              |                         |
| >                                          |                         |
| > M&TE next calibration due date: M&TE not |                         |
| > within tolerance required before         |                         |
| > calibration---M&TE evaluation RPT        |                         |
| > attached                                 |                         |
+--------------------------------------------+-------------------------+
| 21\. M&TE Coordinator: [     ]{.underline} |                         |
| [     ]{.underline}                        |                         |
|                                            |                         |
| Print name and Title/Signature Date        |                         |
+--------------------------------------------+-------------------------+