Value Assignment | Quantimetrix

Laboratory Information

Laboratory Name:*

Laboratory Manager:*

Address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Phone*

Fax

Email*

Please fill out the information for the person that completed this survey in the spaces below.

Name*

Title*

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

By entering your name here and submitting your laboratory information for our Value Assignment Program, you are authorizing Quantimetrix Corporation to contact you for this purpose. We will not use your information for any other purpose. We will contact you once your information is received. Thank you.

Signature:*

Analyzer(s) Used

Please list the analyzer(s) currently used in your laboratory:

Please check all assays performed in your lab:

CLIA, COLA, DAP, CLIP Certification

Is your facility certified by any of the above agencies?

Yes
No

If yes, please complete the following:

Date of last inspection:

Certification number:

We will contact you for a copy of your certification upon receipt of your survey.

Is there an internal quality audit program that covers all areas of operation to verify that procedures and policies are being followed to determine the effectiveness of the quality system?

Yes
No

Is there a procedure for receiving, reviewing, handling and storage of samples?

Yes
No

Are calibration records maintained for each piece of equipment or instrument?

Yes
No

Type any other questions or considerations.

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