Attachment 5a. Test Kit Application and Questions for US Laboratories (Word)
CDC estimates the average public reporting burden for this collection of information as 6 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1313).
OMB No.
0920-1313
Exp. Date 03/31/2026
Applicant Information
First Name [__________]
Last Name [__________]
Institution [__________]
Lab Name (optional) [__________]
Street Address Line 1 [__________]
Street Address Line 2 [__________]
City [__________]
State [__________] (dropdown) * This field is required
Zip/Postal Code [__________]
Email [__________]
Verify Email [__________]
Telephone [__________]
Does your laboratory have a current DEA registration to handle scheduled substances?
[YES/NO] * This field is required
Testing Information
1. Which test kit(s) are you requesting? (provide quantity)
Fentanyl Analog Screening (FAS) Quantity [___]
FAS Version 1 Quantity [___]
FAS Version 2 and 3 Quantity [___]
FAS Version 4 Quantity [___]
Emergent Drug Panel (EDP) Quantity [___]
Emergent Drug Panel – Version 1 (EDP-V1) Quantity [___]
Emergent Drug Panel – Internal Standard (EDP-IS) Quantity [___]
2. Which test kit(s) have you previously received? (provide quantity)
Fentanyl Analog Screening (FAS) Quantity [___]
FAS Version 1 Quantity [___]
FAS Version 2 and 3 Quantity [___]
FAS Version 4 Quantity [___]
Emergent Drug Panel (EDP) Quantity [___]
Emergent Drug Panel – Version 1 (EDP-V1) Quantity [___]
Emergent Drug Panel – Internal Standard (EDP-IS) Quantity [___]
3. Which of the following best describes your laboratory? (Select only one)
Academic Research Laboratory
Environmental Laboratory
Government Crime Laboratory
Government Toxicology Laboratory
Private or Public Clinical Laboratory
Other (please specify) ____________________
4. Which of the following tests or services are performed by your laboratory? (Select all that apply)
Seized drug sample testing
Post-mortem toxicology sample testing
Workplace drug screening
Newborn drug screening
Drug pharmacology and pharmacokinetics research
Clinical testing for disease diagnosis and treatment or surveillance
Other (please specify) ____________________
5. Which of the following drug categories does your laboratory test for? (Select all that apply)
□ Opioids
□ Synthetic Cannabinoids
□ Stimulants and Hallucinogens
□ Benzodiazepines
6. On average, how many opioid, synthetic cannabinoid, stimulant, hallucinogen, or benzodiazepine-related samples does your laboratory analyze on a weekly basis? (Select only one)
< 100
100 - 500
501 - 1000
> 1000
7. Which of the following analytical techniques do you perform in your laboratory? (Select all that apply)
Immunoassay
Infrared Spectroscopy
Mass Spectrometry
Nuclear Magnetic Resonance Spectroscopy
Raman Spectroscopy
X-ray Diffraction
Chromatographic Separation
UV/Vis
Other (please specify) ____________________
8. Which sample matrices does your laboratory analyze? (Select all that apply)
Blood
Urine
Drug Powders
Waste Water
Other (please specify) ____________________
Submit
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | NCEH/ATSDR Office of Science |
File Modified | 0000-00-00 |
File Created | 2024-07-30 |