Laboratory Information Change

Model Performance Evaluation Program for

M. tuberculosis/Non-tuberculous Mycobacteria Drug Susceptibility Testing Program(MTB/NTM DST)

Laboratory Information Change Form

Lab ID# Number:

Please indicate changes to be made to your current laboratory information:

1. Laboratory Name:

2a. Mailing Contact Person:

Name: _____________________________________________________________________

Title: _____________________________________________________________________

Telephone Number: ________________________ FAX Number: ____________________

E-Mail: __________________________________

2b. Shipping Contact Person:

Name: _____________________________________________________________________

Title: _____________________________________________________________________

Telephone Number: ________________________ FAX Number: ____________________

E-Mail: __________________________________

3a. Mailing Address of Laboratory (address which correspondence should be sent):

Street or PO Box: ____________________________________________________________

___________________________________________________

City: _____________________________________ State: ___________________________

Country: __________________________________ Zip/Postal Code: __________________

3b. Shipping Address of Laboratory to which specimens should be mailed if different from above:

*Cultures can not be mailed to PO Boxes

Street: ____________________________________________________________________________

____________________________________________________________________________

City: _____________________________________ State: ___________________________

4. Panels to be shipped to laboratory (check only one): □ M. tuberculosis Only □ NTM Only
□ Both M. tuberculosis and NTM

5. Person Completing Form: _________________________________________________

6. Today’s Date: _____________________________

P

Public reporting of this collection of information is estimated to average 5 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0600)

lease email this form to aragin@cdc.gov or fax to 404 498-2372, Attention: MTB/NTM DST