Clinical Laboratory Licensure and Proficiency Testing Review
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| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CL-3 |
Application for a Clinical Laboratory License
(Onsite Testing Only)
(Updated October 10, 2017) |
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| CL-9 |
Disclosure of Ownership and Control Interest
(Updated October, 2016) |
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| CL-18 |
Application for a Clinical Laboratory License
(Collection Station Only) |
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| CL-34 |
Laboratory Personnel Qualification Appraisal |
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| OCC-34 |
Clinical Laboratory Report of Elevated Levels of Heavy Metals:Lead: In Adults (Greater than 16 Years of Age)Arsenic, Cadmium, Mercury: In Persons of Any Age |
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Blood Bank Licensure and Regulatory Compliance
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| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CL-8 |
Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities) |
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| CL-8A |
Blood Bank Annual Statistics (Hospitals) |
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| CL-13 |
Blood Bank Annual Statistics
(Hematopoietic Progenitor Cell Facilities) |
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| CL-14 |
Blood Bank Annual Statistics
(Perioperative Autologous Blood Collection and Administration Facilities) |
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| CL-16 |
Application for a Blood Bank License |
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| CL-17 |
Blood Bank Annual Statistics (Umbilical Cord Blood Facilities) |
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| CL-21 |
Error/Accident Report
(Updated December 6th, 2024) |
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| CL-40 |
Blood Bank Personnel Qualification Appraisal |
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| CL-44 |
Transfusion Reaction Report
(Updated December 6th, 2024) |
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| CL-50 |
Brokers and Reagent Manufactureres - Annual Statistical Data |
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| CL-51 |
Blood Centers - Annual Statistical Data |
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| CL-58 |
Blood Bank License Fee |
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CLIA Program
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| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CMS-116 |
Clinical Laboratory Improvement Amendments (CLIA) Application for Certification |
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Public Health Laboratory Services
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| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| BACT-44 |
Bacteriological Sample Submittal
(Updated November 28, 2016) |
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| BACT-109 |
Request for Bacterial or Viral Culture or Parasite Identification
(Updated April 22nd, 2024) |
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| IEM-15 |
Order form for Initial Newborn Screening Request (IEM-1) Forms |
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| IEM-67 |
Newborn Screening Bloodspot Destruction Request Form
(Posted January 31, 2025) |
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| IEM-68 |
Newborn Screening Bloodspot Extended Retention Request Form
(Posted January 31st, 2025) |
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| IEM-69 |
Newborn Screening Specimen Release Request Form
(Posted January 31st, 2025) |
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| LAB-3 |
Request for Microbiological Testing of Food Sample |
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| LAB-05 CLINICAL |
Request for Testing of Suspected Pathogens of Public Health Significance and Chain of Custody
(Updated April 22nd, 2024) |
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| LAB-7 |
HIV Test Requisition |
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| LAB-10 |
Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT) |
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| SRD-1 |
Request for Viral Serology, Culture and Molecular Diagnostics
(Updated April 22nd, 2024) |
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| SRD-4 |
Request for Immunological/Isolation Services - Clinical Services Testing Unit |
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| STD-1 |
Sexually Transmitted Disease Requisition Form
(Posted April 22nd, 2024) |
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| TB QFT-1 |
Request for QuantiFERON-TB Gold / Mycobacteriology Culture
(Posted April 22nd, 2024) |
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| VIR-1 |
Requisition for Viral Serology |
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Complete per instructions on form
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| VIR-16 |
Request for Rabies Examination
(Updated April, 2016) |
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Environmental and Chemical Laboratory Services
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| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| BACT-44 |
Bacteriological Sample Submittal
(Updated November 28, 2016) |
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| CHEM-44 |
Organic and Inorganic Chemistry Sample Submittal |
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Instructions for Completing Sample Submittal Forms (pdf 11k)
Instructions for Completing Sample Submittal Forms (doc 26k)
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| PSP-1 |
Questionnaire to Assess Your Exposure Risk for Lead and Mercury (Quicksilver) |
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| RAD-4 |
Radioanalytical Services Sample Submittal |
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Instructions for Completing Sample Submittal Forms (pdf 12k)
Instructions for Completing Sample Submittal Forms (doc 32k)
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