Republic of the Philippines

Department of Health
SAN LAZARO HOSPITAL

National Reference Laboratory for HIV / AIDS, Hepatitis B & C, and Syphilis
STD / AIDS Cooperative Central Laboratory
Quiricada St., Sta. Cruz, Manila
Tel Nos: (632)3109528/29 TeleFax: (632)7114117
website: saccl.doh.gov.ph Email: nrlslhsaccl@yahoo.com.ph

2015 EQAS SEROLOGY

LABORATORY REPORT FORM

Laboratory Code ________
General Information:
Name of Testing Laboratory: ____________________________________________________________
Address: ____________________________________________________________________________
Telephone number: __________________________ Fax No: __________________________________
Email Address of Contact Person: ________________________________________________________
Name of Pathologist: __________________________________________________________________
Name of Medical Technologist who performed the test for:
Anti-HIV 1 & 2 test : _____________________
HBsAg Test: ___________________________
Anti-HCV Test: _________________________
Anti-TP Test ___________________________

PRC Number: __________

PRC Number: __________
PRC Number: __________
PRC Number __________

HIV Prof.Cert. No./Expiry:_________

Date sample/s received: _____________________

Were samples received in good condition?
( ) Yes
( ) No, if no give comment (attested by courier) ________________________________
Demographics (Laboratorys location by region) : ________________ Zip Code: ___________
Type of Laboratory: (check item)
( ) Private Hospital based
( ) Free standing(not connected to hospital/clinic)
( ) Government Hospital based ( ) Clinic based
( ) Others (i.e. RHU, CHO, SHC, NGO, TB-DOTS), specify _____________________________________
Facility:
Centrifuge: ( ) available

( ) not available

( ) available but <10,000rpm

Reporting of Results:
Were you able to encode your results to OASYS? ( )Yes ( )No; If No, give reason for failure to submit result
through the system:
________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
NOTE: INCOMPLETE FILLED UP FORMS ARE NOT ACCEPTABLE
ALL participants, are required to encode their results to OASYS. Failure to encode
means no result submitted and does not warrant the issuance of Certificate of
Participation for the current Test Event.
Page 1 of 3 Laboratory report form

SYPHILIS Testing
LABORATORY REPORT FORM
Laboratory Code _________

RAPID TEST KIT RESULTS (RPR, ICT, Dot Blot, Agglutination, etc)
Information about the test run(s)
(use separate sheet if test is performed more than once using other method)
Full Commercial Name of Assay Used: ____________________________________________________
Manufacturer: _____________________________Address:____________________________________
Name of Distributor/ Importer :________________Address /Tel #:_______________________________
Assay Lot No: ______________________Expiration Date: _________________________________
Date Sample tested: ____________________
Results from test run(s)
Sample ID
(
(
(
(
(

)R
)R
)R
)R
)R

(
(
(
(
(

RESULT
)NR
)NR
)NR
)NR
)NR

(
(
(
(
(

)Inc
)Inc
)Inc
)Inc
)Inc

Note: For Rapid tests, encode one run result only in OASYS; For Nontreponemal tests (e.g.RPR), indicate TITER

MICROTITER IMMUNOASSAY RESULTS(Semi-automated)

Information about the test run(s)
(use separate sheet if test is performed more than once using other method)
Full Commercial Name of Assay Used: _____________________________________________________
Manufacturer: _____________________________Address:____________________________________
Name of Distributor/ Importer :________________Address /Tel #:_______________________________
Assay Lot No: ___________________________________Expiration Date:__________________________
Name/Model of equipment (EIA Reader) used ______________________ Manufacturer______________
Date sample tested: 1st run __________________; 2nd run _______________________
Sample ID

1st run (S/CO ratio)

OD
(A)

Note: INC inconclusive

CutOff
(B)

S/CO
(AB)

2nd run in duplicate(S/CO ratio)

CutOff
(B)

OD(A)
Dup 1

Dup 2

Assay Interpretation

S/CO (AB)
Dup 1

Dup 2
( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

Page 2 of 3 for anti- HIV testing report form

Fully-AUTOMATED IMMUNOASSAY RESULTS

Information about the test run(s)
(use separate sheet if test is performed more than once using other method)
Full Commercial Name of Assay Used: _____________________________________________________
Manufacturer: _____________________________Address:____________________________________
Name of Distributor/ Importer :________________Address /Tel #:_______________________________
Assay Lot No: ___________________________________Expiration Date:__________________________
Name/Model of equipment used _______________________ _____ Manufacturer __________________
Date sample tested; 1st run _______________________; 2nd run _______________________
Results from test run(s)
Sample ID

1st run
( ) S/CO ( )S/N ( )mIU/ml
( ) Others (Pls specify) _________

2nd run in duplicate(S/CO ratio)

( ) S/CO ( )S/N ( )mIU/ml
( ) Others (Pls specify) _________
Dup 1

Assay Interpretation

Dup 2
( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

( )R

( )NR

( )Inc

Note: INC means inconclusive

Frequency of use of internal QC ( using known (-) and (+) excluding ICT controls in anti-HIV 1&2 test device), every
( ) test run ( ) new operator
( ) new lot
( ) daily
( ) weekly
( ) monthly
( ) shift
( ) after certain number of tests ( ) others __________
Do you use other quality control samples (not included in anti-HIV 1 & 2 test kit) in your regular testing?
( )No ( ) if yes complete information below
Source: ( ) In-house, prepared by own laboratory
( ) Commercial, pls specify name: ________________________
Do you do anti-HIV confirmatory test? ( )yes ( )no
If yes, Indicate brand/manufacturer of reagent used ________________________________________
If no, what do you do with initially reactive results?
( ) report initial test result
( ) refer , to whom?
( ) other referral laboratory
( ) NRL
( ) repeat testing
( ) using same kit, then report result
( ) using another kit, different principle, report
( ) other
Name of person completing these anti-TP test result forms: ____________________________________
Name/ Designation (Sign over printed name)
Date:_____________________
Supervisor: __________________________________
Name/ Designation (Sign over printed name)
Date: _________________
Page 3 of 3 for anti- TP testing report form