Protocol For Conducting The Health Screening Events In The State Of Illinois Page 2
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3Once notification is received, the Department will e-mail a confirmation. It is recommended to have the
acknowledgment letter or e-mail from our office printed and ready to be displayed in case one of our surveyors visits the
event.
Following is a summarized protocol for conducting health screenings in the state of Illinois. However, we recommend for
health screening entities to review the required and detailed protocols that can be found at the website:
SUBPART M: HEALTH SCREENING
•
Section 450.1300 Health Screening and Approved Health Screening Tests
•
Section 450.1310 Protocol for Conducting Health Screening
•
Section 450.1330 Reporting and Notification
AGENCY NOTE: Any entity which performs health screening events shall establish a protocol for health
screening activities and submitted the completed document to our office for review and approval.
Protocol for Conducting the Health Screening Events in the State of Illinois
All fields must be answered and protocol signed, dated and approved by a physician licensed to practice medicine in all its branches.
Facilities performing health screening events must have the endorsement for Temporary Testing added to their certificate.
Check this box
if you would like to have the endorsement added to this CLIA certificate.
Facility CLIA ID # _______________ Facility Name ___________________________________________________
Address ________________________________________ State __________________ Zip Code ________________
1)
Indicate the name of all CLIA Waived test(s) to be conducted. __________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2)
Indicate the way in which results shall be reported to the test subject including any available oral
counseling and health professional referral program. ___________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3)
Indicate how confidentiality will be maintained. ______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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