Form Cms-1557 - Survey Report Form - Clia printable pdf download

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0544

SURVEY REPORT FORM (CLIA)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number.

The valid 0MB control number for this information collection is 0938-0544. The time required to complete this information collection is estimated to average 30 min-

utes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information col-

lection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security

Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SURVEYOR INSTRUCTIONS FOR CMS 1557

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For specialty(ies)/subspecialty(ies) added or deleted: Use the space provided to list corresponding information and effective dates.

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For proficiency testing: Any comments pertinent to the survey or determination of compliance can be listed here.

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Each surveyor must sign the certifying statement on page 2 for each type of survey conducted (see “survey status;” “other” may include

follow-up visit to verify a POC).

GENERAL INFORMATION

CLIA IDENTIFICATION NUMBER

DATE OF SURVEY

LABORATORY NAME

TELEPHONE NUMBER (include area code)

LABORATORY ADDRESS (number, street)

CITY

STATE

ZIP

MAILING ADDRESS (if different from above)

CITY

STATE

ZIP

NAME OF DIRECTOR

last

first

STATE/COUNTY CODE

STATE REGION CODE

SURVEY STATUS: (Check all that apply)

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Initial Certification

State Exemption (State) ______________________

STATE LICENSE NUMBER (if applicable)

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Accreditation (Organization) ___________________

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Recertification

_________________________________________

MEDICARE PROVIDER NUMBER(S)

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Validation

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Addition of (Sub)Specialty(ies)

_______________________

______________________

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Complaint

Other (Specify) _____________________________

_______________________

______________________

_______________________

______________________

PERSONNEL: SHOW NUMBER OF PEOPLE QUALIFIED UNDER EACH APPLICABLE REGULATORY SECTION

DIRECTOR

CLINICAL CONSULTANT

TECHNICAL CONSULTANT

MODERATE COMPLEXITY

493.1405(a) and

493.1417

493.1411(a) and

(b)(1) ________ (6) ________

(a) ________

b) (1) ________ ( ) ________

(2) ________ (7) ________

(b) ________

(2) ________ ( ) ________

(3) ________ ( ) ________

( ) ________

(3) ________

(4) ________ ( ) ________

( ) ________

(4) ________

(5) ________ ( ) ________

CLINICAL CONSULTANT

TECHNICAL SUPERVISOR

GENERAL SUPERVISOR

DIRECTOR

HIGH COMPLEXITY

493.1461(a) and

493.1455

493.1449(a) and

493.1443(a) and

(b) ______ (h) ______ (n) ______

(b)(1) _______ (d)(1) _______

(b)(1) _______ ( ) _______

(a) ________

(b)(2) _______ (d)(2) _______

(2) _______ ( ) _______

(d) ______ (j) ______ (p) ______

(b) ________

(c)(1) _______ (d)(3) _______

(3) _______

(e) ______ (*)______ (q) ______

( ) ________

(f) ______ (l) ______ ( ) ______

(c)(2) _______ (e) _________

(4) _______

( ) ________

(g) ______ (m) ______ ( ) ______

(c)(3) _______ ( ) _________

(5) _______

CYTOTECHNOLOGIST

TECHNICAL SUPERVISOR

GENERAL SUPERVISOR

493.1483(a) and

CYTOLOGY

*493.1449(a) and

493.1469

(b)(1) _______ (4) _______

(k)(1) _______ ( ) _______

(a) _______ ( ) _______

(2) _______ (5) _______

(2) _______ ( ) _______

(b) _______ ( ) _______

(3) _______ ( ) _______

FORM CMS-1557 (9-92)

PAGE 1

Form Cms-1557 - Survey Report Form - Clia

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