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NRL-SACCL NEQAS REGISTRATION FORM

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NRL-SACCL NEQAS REGISTRATION FORM Powered By Docstoc
					                                                      Republic of the Philippines
                                                        Department of Health
                                                      SAN LAZARO HOSPITAL
                           National Reference Laboratory for HIV / AIDS, Hepatitis B & C, and Syphilis
                                            STD / AIDS Cooperative Central Laboratory
                            Quiricada St., Sta. Cruz, ManilaTel Nos: 632-3099528 TeleFax: 632-7114117
ANNEX-1                                website: www.doh.gov.ph/saccl            Email: nrl_saccl@yahoo.com.ph




                  NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME (SEROLOGY)
                                     2011 Registration Form

     A. LABORATORY INFORMATION (Write in bold letters, no abbreviations)

    Name of Clinical Laboratory: _________________________________________________________________________________

    Contact Person to whom test material is to be dispatched: _______________________________________________________

    Position: _______________________________ Email of contact person (mandatory): ________________________________

    Tel. No: _________________________ Mobile No: _________________________ Fax No: _____________________________

    Address: _________________________________________________________________________________________________

                 _________________________________________________________________________________________________


    Type of Testing Site: (check all items that apply)                                                  Licence To Operate (LTO #):
     (   ) Private Hospital, check type: ( ) Diagnostic lab ( ) Blood Screening Center                  Issued on:
     (   ) Government Hospital, check type: ( ) Diagnostic lab ( ) Blood Screening Center               Valid until:
     (   ) Free standing, indicate if catering to: ( )OFW only ( ) General Population ( ) Both
     (   ) Others (i.e. RHU, CHO, SHC)


     B. LABORATORY PERSONNEL
    Name of Pathologist:                                                                    Mobile:

                                                                                            Email (mandatory):
    Name of Chief Med Tech:                                                                 Mobile:

                                                                                            Email:
    Name of HIV Proficient Med Tech:                                                        Mobile:

    Proficiency Cert No:                                                                    Email:

     C. AVAILABLE SEROLOGIC TEST (please check box)
      Check box which tests does           Method                                                     Name/Brand of kit used
       your laboratory wants to
               participate in
    ( ) anti-HIV                 ( ) Rapid     ( ) EIA                         Anti-HIV :
    ( ) anti-HCV                 ( ) Rapid     ( ) EIA
    ( ) HBsAg                    ( ) Rapid     ( ) EIA                         Anti-HCV:
    ( ) Syphilis                 ( ) Rapid ( ) RPR ( ) EIA
    ( ) not interested                                                         HBsAg:

                                                                               Syphilis-RPR :

                                                                                        EIA:

                                                                                       PA/HA:

     D. Annual CENSUS:
             Test Done                     Total Number of test done           Total Number –Reactive              Total Number- Positive
                                                    (2010)                         (Screening test)                  (Confirmatory test)
                 Anti-HIV
                 Anti-HCV
                  HBsAg
                  Syphilis


  _______________________________________________________________________________________________________________
  This laboratory agrees to abide by the rules of participation of the External Quality Assessment Scheme

  Conformed by:
     Name/Signature: _____________________________________________________________________

     Position:          ____________________________                 Date: ________________________________

				
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Description: A copy of the registration form for NRL-SACCL 2011 NEQAS.