Clinical Laboratory Licensure and Proficiency Testing Review
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CL-3 |
Application for a Clinical Laboratory License
(Onsite Testing Only)
(Updated October 10, 2017) |
|
|
| CL-9 |
Disclosure of Ownership and Control Interest
(Updated October, 2016) |
|
|
| CL-18 |
Application for a Clinical Laboratory License
(Collection Station Only) |
|
|
| CL-34 |
Laboratory Personnel Qualification Appraisal |
|
|
| OCC-34 |
Clinical Laboratory Report of Elevated Levels of Heavy Metals:Lead: In Adults (Greater than 16 Years of Age)Arsenic, Cadmium, Mercury: In Persons of Any Age |
|
|
Blood Bank Licensure and Regulatory Compliance
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CL-8 |
Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities) |
|
|
| CL-8A |
Blood Bank Annual Statistics (Hospitals) |
|
|
| CL-13 |
Blood Bank Annual Statistics
(Hematopoietic Progenitor Cell Facilities) |
|
|
| CL-14 |
Blood Bank Annual Statistics
(Perioperative Autologous Blood Collection and Administration Facilities) |
|
|
| CL-16 |
Application for a Blood Bank License |
|
|
| CL-17 |
Blood Bank Annual Statistics (Umbilical Cord Blood Facilities) |
|
|
| CL-21 |
Error/Accident Report |
|
|
| CL-40 |
Blood Bank Personnel Qualification Appraisal |
|
|
| CL-44 |
Transfusion Reaction Report |
|
|
| CL-50 |
Brokers and Reagent Manufactureres - Annual Statistical Data |
|
|
| CL-51 |
Blood Centers - Annual Statistical Data |
|
|
| CL-58 |
Blood Bank License Fee |
|
|
CLIA Program
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CMS-116 |
Clinical Laboratory Improvement Amendments (CLIA) Application for Certification |
|
|
Public Health Laboratory Services
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| BACT-44 |
Bacteriological Sample Submittal
(Updated November 28, 2016) |
|
|
| BACT-109 |
Request for Bacterial or Viral Culture or Parasite Identification |
|
|
| IEM-15 |
Order form for Initial Newborn Screening Request (IEM-1) Forms |
|
|
| LAB-3 |
Request for Microbiological Testing of Food Sample |
|
|
| LAB-5 CLINICAL |
Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody |
|
|
| LAB-7 |
HIV Test Requisition |
|
|
| LAB-10 |
Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT) |
|
|
| SRD-1 |
Request for Viral Serology, Culture and Molecular Diagnostics |
|
Instructions included on page 2 of form.
Map (pdf 37k)
|
| SRD-4 |
Request for Immunological/Isolation Services - Clinical Services Testing Unit |
|
|
| VIR-1 |
Requisition for Viral Serology |
|
Complete per instructions on form
|
| VIR-16 |
Request for Rabies Examination
(Updated April, 2016) |
|
|
Environmental and Chemical Laboratory Services
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| BACT-44 |
Bacteriological Sample Submittal
(Updated November 28, 2016) |
|
|
| CHEM-44 |
Organic and Inorganic Chemistry Sample Submittal |
|
Instructions for Completing Sample Submittal Forms (pdf 11k)
Instructions for Completing Sample Submittal Forms (doc 26k)
|
| PSP-1 |
Questionnaire to Assess Your Exposure Risk for Lead and Mercury (Quicksilver) |
|
|
| RAD-4 |
Radioanalytical Services Sample Submittal |
|
Instructions for Completing Sample Submittal Forms (pdf 12k)
Instructions for Completing Sample Submittal Forms (doc 32k)
|
