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Please
indicate your laboratory type by checking the appropriate category
listed below:
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[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]
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[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]
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[e.g., city, county, state (main, central, or branch), regional,
district, national reference laboratory (government
affiliated)]
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[e.g., commercial, commercial manufacturer of reagents,
pharmaceutical laboratory, employee health clinic, reference
laboratory (nongovernment affiliated)]
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[e.g.,
university-associated research, drug screening/toxicology, Federal
government research (nonmilitary), organ procurement, privately
funded research] |
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) |
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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). |
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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.
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This page last reviewed: 11/15/2006
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