Model Performance Evaluation Program (MPEP)

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Model Performance Evaluation Program (MPEP)

For Retroviral and AIDS-Related Testing
OMB Form Number 0920-0274 Expiration Date: 02/28/2011

For enrollment of your laboratory in the Model Performance Evaluation Program (MPEP), please provide information in the spaces below. This information will be entered in the MPEP enrollment data base to ensure your laboratory's receipt of mailed performance evaluation panels and CDC published reports of results.

Name of Laboratory:
Mailing Address:
City:
State:
Zip Code:
Country:

Laboratory Director's Name:
Laboratory Supervisor's Name:

Please indicate the MPEP program(s) in which your laboratory would like to participate:

HIV-1 Rapid Testing
YesNo

If you checked "No" to any of the items above, please indicate why below:

Our laboratory does not perform HIV-1 Rapid testing.

Other reasons, please specify (optional):

Please indicate your laboratory type by checking the appropriate category listed below:

BLOOD BANK [e.g., community, regional, blood/plasma center, Red Cross, privately owned, military, non-hospital blood bank, hospital blood bank (hospital blood bank includes portion of hospital laboratory responsible for blood donor testing]

HOSPITAL [e.g., city, county, district, community, state, regional, military, Veterans Affairs, Federal government (other than military), privately owned, university, HMO/PPO owned and operated, religious-associated]

HEALTH DEPARTMENT [e.g., city, county, state (main, central, or branch), regional, district, national reference laboratory (government affiliated)]

INDEPENDENT [e.g., commercial, commercial manufacturer of reagents, pharmaceutical laboratory, employee health clinic, reference laboratory (nongovernment affiliated)]

FAMILY PLANNING CENTER

HEALTH MAINTENANCE ORGANIZATION (HMO)

MEDICAL EXAMINER/CORONER

PHYSICIAN'S OFFICE

SEXUALLY TRANSMITTED DISEASES CLINIC

CORRECTIONAL FACILITY

COUNSELING AND TESTING SITE

DRUG USE TREATMENT CENTER

MILITARY [other than blood bank or hospital, e.g. induction center]

MOBILE UNIT [other than blood donation]

COMMUNITY BASED ORGANIZATION

OTHER [e.g., university-associated research, drug screening/toxicology, Federal government research (nonmilitary), organ procurement, privately funded research]

Please verify your desire to participate in the MPEP by reading the following and signing in the space provided.

We understand that as participants in the Model Performance Evaluation Program, we will be asked to send the following to CDC: (1) results of our testing of performance evaluation samples provided by CDC; (2) information on methods used to test the samples; and (3) information about the characteristics and testing practices of our laboratory.

Director's Name:

Please indicate below both the name of the contact person and the laboratory shipping address where performance evaluation panels should be mailed:

(Please note that performance evaluation samples shipments cannot be delivered to P.O. boxes located in the United States)

HIV Rapid Testing
HIV Rapid Testing Contact Person:
Shipping Address:
City:
State:
Zip Code:
Territory:
Telephone:	Ext:
Fax:
Email:

Revised: November 15, 2006.

Public reporting burden for this collection of information is estimated to average three minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, N.E., MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0274).

If you have questions about the completion of this enrollment information, please call Sandra Neal at (404)718-1006 or Leigh Vaughn at (404)718-1005 or Fax at (404)718-1080.

This page last reviewed: 11/15/2006

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