Form Cms-1557 - Survey Report Form - Clia Page 2

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(SUB)SPECIALTY(IES)
(SUB)SPECIALTY(IES)
ACCREDITED
PROFICIENCY
ANNUAL TEST
SPECIALTIES/SUBSPECIALTIES
ADDED
DELETED
TESTING
PROGRAM
VOLUMES
EFFECTIVE DATE
EFFECTIVE DATE
■
010
Histocompatibility
__________
_________
______________
_____________
NA
■
A
Transplant
■
B
Nontransplant
■
100
Microbiology
__________
_________
______________
_____________
_________
■
110
Bacteriology
__________
______________
_____________
_________
■
115
Mycobacteriology
__________
______________
_____________
_________
■
120
Mycology
__________
______________
_____________
_________
■
130
Parasitology
__________
______________
_____________
_________
■
140
Virology
__________
______________
_____________
_________
■
150
Other
__________
______________
_____________
_________
■
200
Diagnostic Immunology
__________
_________
______________
_____________
_________
■
210
Syphilis Serology
__________
______________
_____________
_________
■
220
General Immunology
__________
______________
_____________
_________
■
300
Chemistry
__________
_________
______________
_____________
_________
■
310
Routine
__________
______________
_____________
_________
■
320
Urinalysis
__________
______________
_____________
_________
■
330
Endocrinology
__________
______________
_____________
_________
■
340
Toxicology
__________
______________
_____________
_________
■
350
Other
__________
______________
_____________
_________
■
400
Hemotology
__________
_________
______________
_____________
_________
■
500
Immunohematology
__________
_________
______________
_____________
_________
■
510
ABO Group & Rh Type
__________
______________
_____________
_________
■
520
Antibody Detection
__________
______________
_____________
_________
(transfusion)
■
530
Antibody Detection
__________
______________
_____________
_________
(nontransfusion)
■
540
Antibody Identification
__________
______________
_____________
_________
■
550
Compatibility Testing
__________
______________
_____________
_________
■
560
Other
__________
______________
_____________
_________
■
600
Pathology
__________
_________
______________
_____________
_________
■
610
Histopathology
__________
______________
_____________
NA
■
620
Oral pathology
__________
______________
_____________
NA
■
630
Cytology
__________
______________
_____________
_________
■
800
Radiobioassay
__________
_________
______________
_____________
NA
■
900
Clinical Cytogenetics
__________
_________
______________
_____________
NA
■
■
Are immunohematology tests performed for transfusion purposes? .........................................................................................
Yes
No
■
■
Are blood and/or blood products (including autologous) collected? ..........................................................................................
Yes
No
For a partial survey (validation, addition of (sub)specialty, complaint, or follow-up) list the laboratory condition(s) regulation number(s)
reviewed:
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
In accordance with current survey procedures, this laboratory was found to be in compliance with program requirements.
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
DATE
FORM CMS-1557 (9-92)
PAGE 2

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