Republic of the Philippines

Department of Health
SAN LAZARO HOSPITAL
National Reference Laboratory for HIV / AIDS, Hepatitis & Other STIs
STD / AIDS Cooperative Central Laboratory
Quiricada St., Sta. Cruz, ManilaTel Nos: 632-3109528/29 TeleFax: 632-7114117
website: www/nrlslhsaccl.com.ph Email: saccl_eqas@yahoo.com

NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME (SEROLOGY)

2018 Registration Form

Check if ( ) New Participant ( ) Old Participant, indicate Laboratory Code (Ex: SACN001)

A. LABORATORY INFORMATION (Write legibly in bold letters, no abbreviation, fill-up all spaces with needed information )

Name of Clinical Laboratory:

Address:

Zip Code: Region:

Contact Person(Laboratory) to whom test material is to be dispatched:

Position: Email of laboratory/ contact person ( mandatory ):

Lab Tel. No: Lab Fax No: Mobile No. of contact person:

Type of Testing Site: (check all items that apply)

Private: ( ) Hospital Diagnostic lab ( ) Hospital Blood Screening Center ( ) Both ( ) Free Standing lab (non-hospital based)
Government: ( ) Hospital Diagnostic lab ( ) Hospital Blood Screening Center ( )Both ( )SHC, CHO, RHU, TB-DOTS

B. LABORATORY PERSONNEL
Name of Pathologist: Mobile No:
Email :
Name of HIV Proficient Med Tech: Mobile No:
Proficiency Cert No: Year of last renewal: Email :
Assigned Section: ( ) Diagnostic ( ) Blood Bank Service ( ) Both
(use separate sheet if more than one proficient med tech is in your institution)

C. AVAILABLE SEROLOGIC TEST (please check box)

Check box which tests does Method Name/Brand of kit used
your laboratory want to
participate in
( ) anti-HIV ( ) Rapid ( ) IA Anti-HIV :
( ) anti-HCV ( ) Rapid ( ) IA Anti-HCV:
( ) HBsAg ( ) Rapid ( ) IA HBsAg:
( ) Syphilis ( )Rapid ( ) IA Syphilis:
IA – Immunoassay (machine –based)

D. Annual CENSUS:
Test Done Total Number of test done Total Number –Reactive Total Number- Positive
(2017) (Screening test) (Confirmed positive)
Anti-HIV
Anti-HCV
HBsAg
Syphilis

E. Is there an available courier service near your area?

( ) YES , name of Courier service(s) ___________________DFD___________________________________________
( ) NO, if none, indicate another address(with available courier service) and contact person where your EQAs
panels can be sent

F. What is your laboratory’s performance rating in the previous EQAS (2017)

HIV ( )Excellent ( )Satisfactory ( )Unsatisfactory
HBV ( )Excellent ( )Satisfactory ( )Unsatisfactory
HCV ( )Excellent ( )Satisfactory ( )Unsatisfactory
SYP ( )Excellent ( )Satisfactory ( )Unsatisfactory

If your rating is Satisfactory/Unsatisfactory, fill-up and submit corrective action form.

G. Does your institution have the following certification/accreditation?

( ) No ( ) Yes, check all that applies ( )ISO 9001:2008 ( )ISO15189:2012 ( )Others

This laboratory agrees to abide by the rules of participation of the External Quality Assessment Scheme

Conforme:
Signature over Printed Name/Designation
(Head of Agency or Pathologist or Chief Medical Technologist or QA Manager)
 Republic of the Philippines
Department of Health
SAN LAZARO HOSPITAL
National Reference Laboratory for HIV / AIDS, Hepatitis & Other STIs
STD / AIDS Cooperative Central Laboratory
Quiricada St., Sta. Cruz, ManilaTel Nos: 632-3109528/29 TeleFax: 632-7114117
website: www.nrlslhsaccl.com.ph Email: saccl_eqas@yahoo.com

CORRECTIVE ACTION FORM

Name of Laboratory:

Lab Code:

Error/s:

Action/s Taken to Identify Source of Error:

Action/s Taken to Correct Error:

Comments:

Date:
Name/Signature of Medical Technologist

Date:
Name/Signature of Supervisor/Pathologist