CDC Model Performance Evaluation Program (MPEP) Enrollment Form

OMB Form No. 0920-0274

Expiration Date: 10/31/2007

Centers for Disease Control and Prevention (CDC) - Model Performance Evaluation Program (MPEP)

For Retroviral and AIDS-Related Testing

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.

1. Name of Laboratory: __________________________________________________________________________

2. Mailing Address: ______________________________________________________________________________

3. City: State: Zip Code: Country: ___________ _______

4. Laboratory Director's Name: ________________________________________________________ _______

5. Laboratory Supervisor's Name: _____________________________________________________________

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

HIV-1 Antibody HIV-1 Rapid Testing

[ ]Yes [ ]No [ ]Yes [ ]No

If you checked No to any of the items in question #6, please indicate why below:

[ ] Our laboratory does not perform HIV-1 antibody testing. [ ] Our laboratory does not perform HIV-1 rapid testing.

[ ] Other reasons, please specify (optional):____________________

7. Please indicate your laboratory type by checking the appropriate category listed below (check only one):

[ ] BLOOD BANK [e.g., community, regional, blood/plasma center, Red Cross, privately owned, military, nonhospital 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, 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]

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-74, Atlanta, GA 30333, ATTN: PRA (0920-0274).

Please specify: __________________________________________________

8. 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 Signature: _____________________________________________________________

9. Please indicate below both the name of the contact person and the laboratory shipping address where performance evaluation panels should be mailed if this is different than the mailing address listed above (Please note that performance evaluation samples shipments cannot be delivered to P.O. boxes located in the United States):

HIV Antibody Contact Person: __________________________________________________________________

Shipping Address: _____________________________________________________________________________

City: State: Zip Code: Territory: ____________________

Telephone:( )- - Ext. Fax:( )- - _______________

E-mail: _______________________________________________

HIV Rapid Testing Contact Person: _____ ______________________ _________________________________

Shipping Address: _____________________________________________________________________________

City: State: Zip Code: Territory: ____________________

Telephone:( )- - Ext. Fax:( )- -______________

E-mail: _______________________________________________

10. Please mail this completed enrollment information to:

MPEP Survey Coordinator

Constella Group, LLC

Three Corporate Boulevard

Corporate Square, Suite 600

Atlanta, Georgia 30329

If you have questions about the completion of this enrollment information, please call Constella Group, LLC, at (404) 325-2660, toll free at 1-800-642-6941, or FAX to (404) 325-2667.

If you have questions about participation in the MPEP, please contact by telephone G. David Cross, M.S. (404-718-1004), Manager, or by faxing to (404) 718-1080, or writing directly to:

G. David Cross, M.S., Manager

Model Performance Evaluation Program

Laboratory Practice Evaluation and Genomics Branch

Division of Laboratory Systems, Mailstop G-23

National Center for Preparedness, Detection, and Control of Infectious Diseases

Coordinating Center for Infectious Diseases

Centers for Disease Control and Prevention (CDC)

1600 Clifton Road, N.E.

Atlanta, GA 30333