Form Cms-209 - Laboratory Personnel Report (Clia)
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1
2Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0151
CENTERS FOR MEDICARE & MEDICAID SERVICES
LABORATORY PERSONNEL REPORT (CLIA)
(For moderate and high complexity testing)
1. LABORATORY NAME
2. CLIA IDENTIFICATION NUMBER
3. LABORATORY ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP CODE
4. Instructions:
Positions:
5. TELEPHONE
)
(INCLUDE AREA CODE
a. List below all technical personnel, by name, who are employed
D-Director
CC - Clinical Consultant
by the laboratory. Check (4) the appropriate column for each
TC - Technical Consultant
position held. For TC and TS follow instructions on reverse.
FOR OFFICIAL USE ONLY
TS - Technical Supervisor
b. Indicate whether shift worked is (1) day, (2) evening or (3) night.
GS - General Supervisor
(NOT TO BE COMPLETED BY LABORATORY)
c. Indicate highest level of testing for which personnel are
TP- Testing Personnel
QUALIFIES ACCORDING TO SUBPART M
qualified: Use (M) for moderate and (H) for high complexity.
CT/GS - Cytology General Supervisor
d. Indicate whether position held is full (F) or part-time (P).
CT - Cytotechnologist
DATE OF SURVEY ___________________________
a.
b.
c.
d.
S
1
M
F
PO
SITIO
N H
ELD
EMPLOYEE NAMES
H
I
2
OR
OR
LAST NAME
FIRST NAME
MI
D CC
TC
TS
GS
TP
CT
F
CT/GS
H
P
T 3
o
Check (
) here if additional space is needed to list all technical personnel. Copy this page and attach continuation
4
sheet(s) to the original form.
READ THE FOLLOWING CAREFULLY BEFORE SIGNING
Statement or Entities Generally: Whoever, in any manner within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes false, fictitious or
fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false,
fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.
(U.S. Code, Title 18, Sec. 1001)
CERTIFICATION: I CERTIFY THAT ALL OF THE INDIVIDUALS LISTED ABOVE QUALIFY, TO FUNCTION IN THE POSITION INDICATED,
ACCORDING TO THE PERSONNEL REGULATIONS OF 42 CFR PART 493 SUBPART M.
6. SIGNATURE OF LABORATORY DIRECTOR
7. DATE
IF CONTINUATION SHEET PAGE ___ OF ___
FORM CMS-209 (09/92)
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Parent category: Medical