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| Question | Answer |
|---|---|
| Form Name | Saccl Doh Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | nrl saccl website, saccl, serology eqas 2021, saccl forms |
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, ManilaTel Nos:
website: saccl.doh.gov.ph Email: nrlslhsaccl@yahoo.com.ph
NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME (SEROLOGY)
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2013 Registration Form |
Check if ( ) New Participant |
( ) Old Participant, indicate Laboratory Code:______________ |
A. LABORATORY INFORMATION (Write legibly in bold letters, no abbreviations)
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 ( ) Clinic ( ) OFW ( ) Diagnostic laboratory
Government: ( ) Hospital Diagnostic lab ( ) Hospital Blood Screening Center ( ) Clinic : SHC, CHO, RHU
B. LABORATORY PERSONNEL
Name of Pathologist: |
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Mobile No: |
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Email (mandatory): |
Name of Chief Med Tech/QA Officer: |
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Mobile No: |
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Email (mandatory): |
Name of HIV Proficient Med Tech: |
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Mobile No: |
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Proficiency Cert No: |
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Email (mandatory): |
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Assigned Section: ( ) Diagnostic ( ) Blood Bank Service ( ) Both |
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(use separate sheet if more than one proficient med tech in your institution) |
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C. AVAILABLE SEROLOGIC TEST (please check box) |
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Check box which tests does |
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Method |
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Name/Brand of kit used |
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your laboratory wants to |
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(mandatory) |
participate in |
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( ) |
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) Rapid |
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) EIA |
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( ) |
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) Rapid |
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) EIA |
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( ) HBsAg |
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) Rapid |
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) EIA |
HBsAg: |
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D. Annual CENSUS:
Test Done |
Total Number of test done |
Total Number |
Total Number- Positive |
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(2012) |
(Screening test) |
(Confirmatory test) |
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HBsAg |
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Syphilis |
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E. Is there an available courier service near your area? (mandatory)
( ) YES , name of Courier service(s) ______________________________________________________________
( ) 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 (2012) |
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HIV |
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)Excellent |
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)Satisfactory |
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)Unsatisfactory |
HBV |
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)Excellent |
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)Satisfactory |
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)Unsatisfactory |
HCV |
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)Excellent |
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)Satisfactory |
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)Unsatisfactory |
If your rating is Satisfactory/Unsatisfactory,
This laboratory agrees to abide by the rules of participation of the External Quality Assessment Scheme
Conformed by: (Head of Agency or Pathologist or Chief Medical Technologist)
Name/Signature: _____________________________________________________________________
Position: |
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Date: ________________________________ |
CORRECTIVE ACTION FORM
Name of Laboratory: _____________________________________________________
Lab Code: _____________
Error: __________________________________________________________________
__________________________________________________________________
Action/s Taken to Identify Source of Error:
__________________________________________________________________
__________________________________________________________________
Action/s Taken to Correct Error:
__________________________________________________________________
__________________________________________________________________
Comments:
__________________________________________________________________
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_________________________________ Date____________
Name/Signature of Medical Technologist
_________________________________ Date____________
Name/Signature of Supervisor/Pathologist