VITAL-EQA Enrollment Form National

Yes	Participant Registration Form for VITAL-EQA Fill all applicable yellow fields from sections 1 - 4.									Form Approved OMB No. 0920-xxxx Exp. Date xx/xx/20xx
No
	Please fully complete this form and return it to vitaminalab@cdc.gov
	1. Participant Information for Enrollees
	1	Are you a new Enrollee (Yes/No)? If yes, skip to question 3
	2					Existing VITA-EQA participants enter your VITAL-EQA Lab ID #
	3	Enter the EQA year for which you are registering (ex: 2019)
	4	Company/Institution:
	5	Primary Contact (First and Last Name):
	6	Telephone Number:
	7	Email:
	8	OPTIONAL: Additional or Alternate Email address:
	2. VITAL-EQA Analytes
		Sample Sets	Assay	Will Participate in Spring (April) Round (Yes/No to all)	Will Participate in Fall (October) Round (Yes/No to all)	VITAL-EQA vials contain 1mL of serum each Is > 1mL needed to conduct 2 measurements per vial? SEE NOTE BELOW
	1	B-Vitamins Set	Vitamin B12
	2		Folate
	3	Iron Indicators Set	CRP
	4		Ferritin
	5		sTfR
	6	Fat-Soluble Vitamins Set	Retinol
	7		25-hydroxy-vitamin D
		NOTE: Due to limited quantities of VITAL-EQA materials, we are unable to send more than one kit per analyte group to participants unless we recently received data demonstrating your need for the multiple sets (i.e. data showing that vials were combined or separate sets were used to conduct the full analysis associated with that panel). Unfortunately, we are unable to provide back-up vials or replace lost or damaged kits.
	3. Shipping Details/Notes/Comments
	1	Do you want to receive both Spring and Fall samples together in one shipment (Yes/No)?
	2	Can you accept shipments with dry ice (Yes/No)?
	3	Can we charge the shipment to your shipping carrier account (Yes/No)?
	4	Please provide your shipping carrier and account number:			Carrier:
		Account Number:
	5	Please type your Exact Shipping Address below:
		Recipient Name
		Your Institution Name
		Your Shipping Address
		Your Phone
		Your Email
	4. Additional Notes/Comments/Documents
		Please direct any questions to the VITAL-EQA administrator at vitaminalab@cdc.gov