Form Dtl-Coa-Af-2007 - Application For Accreditation Of Drug Testing Laboratory

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Form DTL-COA-AF-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL:
Application for Accreditation of Drug Testing Laboratory
1
Name of Laboratory
:____________________________________________________
Address of the Laboratory :____________________________________________________
No. & Street
Barangay
____________________________________________________
City/ Municipality
Province
Region
Telephone/ Fax No.
:____________________________________________________
Name of Head of the
Laboratory
:____________________________________________________
Name of Owner
:____________________________________________________
Contact No.
:____________________________________________________
Classification According to
Ownership
: [ ] Government
[ ] Private
Character
: [ ] Institution-Based
[ ] Free-Standing
Service Capability
: [ ] Screening
[ ] Confirmatory
Status of Application
: [ ] Initial
[ ] Renewal
[ ] New
Accreditation No. ____________
[ ] Late Filing
Date Issued ________________
[ ] Transfer of Site
Expiry Date _________________
[ ] Change of Business
Name/ Ownership
Checklist of Application Documents
Please tick (
) the appropriate boxes under column B or C. Items shaded are not required.
A
B
C
Documents
For Initial
For Renewal
1.
Notarized Application for Accreditation of Drug Testing Laboratory (this form)
2.
Letter of Endorsement to the BHFS Director (if filed at CHD)
3.
List of Personnel (use attached form)
4.
Photocopies of the following:
4.1. Proof of qualification of head of the laboratory, analyst and authorized
specimen collector
PRC ID/ PRC Board Certificate, if applicable
PSP Certificate, if applicable
Certificate of Training/ Record of Work Experience
4.2. Proof of employment of head of the laboratory, analyst and authorized
specimen collector
5.
List of Equipment/ Instrument (use attached form)
6.
Duly accomplished Assessment Tool (use attached form)
7.
Documentation of Chain of Custody
1
The name of laboratory should match both DTI/ SEC Registration and Mayor’s/ Business Permit.
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