Form 1 Model Performance Evaluation Program (MPEP) For HIV Rapi

OMB Form No. 0920-0595

Expiration Date: XX/XX/XXXX

Centers for Disease Control and Prevention (CDC)

Model Performance Evaluation Program (MPEP) For HIV Rapid Testing (HIV-RT)

ENROLLMENT FORM

To enroll in the MPEP, please fill in the following form. This information will be entered in the MPEP enrollment database to ensure your laboratory's receipt of mailed performance evaluation panels and CDC published reports of results.

1. Name of Laboratory: (line 1) _______________________________________________________

(line 2) _______________________________________________________

2. Laboratory Contact: (check one): □ Dr. □ Ms. □ Mr. □ Miss □ Mrs. □ Rev. □ Other _________

Name, degree (if applicable): .

Title: .

Phone#: Ext: .

Email: .

FAX#: .

Secondary Phone# (if applicable): Ext: .

Secondary Email (if applicable): .

Secondary FAX# (if applicable): .

3. Mailing Address (line1): _____________________________________

(line2): _____________________________________

4. City: State: Zip Code: Country:

5. Laboratory Director’s Name: _______________________________________________________

Phone#: ______________________ Ext: _______________

Email: __________________________________________

6. Laboratory Supervisor’s Name (if applicable): __________________________________________

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 E-11, Atlanta, GA 30333, ATTN: PRA (0920-0595).

Please specify: __________________________________________________

MPEP HIV-RT Enrollment, continued

8. IMPORTANT! If you are enrolling as part of a group of testing sites, check here □

and contact the MPEP (see contact information below)

9. Please verify your desire to participate in the MPEP by reading the following prior to submitting this form.

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.

10. IF the performance evaluation samples are to be shipped to an address other than the mailing address listed

above, fill in the following information.

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

HIV Rapid Testing Panel Shipment Contact Person:

(check one): □ Dr. □ Ms. □ Mr. □ Miss □ Mrs. □ Rev. □ Other_____

Name, degree (if applicable): .

Title: . Phone#: Ext _

Email: .

FAX#: .

Sample Panel Shipping Facility Name: (line 1) _________________________________________________________

(line 2) _________________________________________________________

Sample Panel Shipping Address: (line 1) ______________________________________________________________

(line 2) ______________________________________________________________

City: State: Zip Code: __________

11. If you have questions about the completion of this enrollment information, please contact below:

• The MPEP by phone (877) 360-8502, email MPEPHIV-RT@cdc.gov , or FAX (404) 498-2391

• Leigh Vaughan, HIV Rapid Testing Project Coordinator by phone (404) 498-2246 or email LVaughan@cdc.gov

• Sandra Neal, MPEP Manager by phone (404) 498-2238

• By writing to:

MPEP Survey Coordinator

Centers for Disease Control and Prevention

Mailstop G-23

1600 Clifton Road, N.E.

Atlanta, Georgia 30329-4018

If you have questions about participation in the MPEP, please contact Sandra Neal, by:

phone (404) 498-2238, fax (404) 498-2391, or by writing directly to:

Sandra W. Neal, B.S., MT(ASCP), M.S., P.M.P.

MPEP Manager

Model Performance Evaluation Program (MPEP)

Laboratory Practice Evaluation and Genomics Branch

Division of Laboratory Systems, Mailstop G-23

Centers for Disease Control and Prevention (CDC)

1600 Clifton Road, N.E.

Atlanta, GA 30329-4018