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Value Assignment
Value Assignment Program
Please complete the survey below and click "submit." Participants must be CLIA certified or certified with an equivalent agency.
Laboratory Information
Laboratory Name:
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Laboratory Manager:
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Address
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Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Afghanistan
Albania
Algeria
American Samoa
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Angola
Antigua and Barbuda
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Armenia
Australia
Austria
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Brazil
Brunei
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Burundi
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Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
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Dominican Republic
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Ethiopia
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Finland
France
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Gambia
Georgia
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Mongolia
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Nigeria
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Poland
Portugal
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Qatar
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Russia
Rwanda
Saint Kitts and Nevis
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Samoa
San Marino
Sao Tome and Principe
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Serbia and Montenegro
Seychelles
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Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
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Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
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Uganda
Ukraine
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United States
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Vietnam
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Virgin Islands, U.S.
Yemen
Zambia
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Country
Phone
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Please fill out the information for the person that completed this survey in the spaces below.
Name
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Title
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Address
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
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:
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Analyzer(s) Used
Please list the analyzer(s) currently used in your laboratory:
Please check all assays performed in your lab:
25-hydroxyvitamin D2/25-hydroxyvitamin D3
Alcohol (Serum)
Ammonia (Serum)
Amylase (Urine)
Apolipoprotein A1 (Serum)
Apolipoprotein A2 (Serum)
Apolipoprotein B (Serum)
Apolipoprotein C2 (Serum)
Apolipoprotein C3 (Serum)
Apolipoprotein E (Serum)
Calcium (Urine)
Chloride (Serum)
Chloride (Urine)
CK-MB (Serum)
CK, Total (Serum)
Creatinine (Urine)
CRP (Serum)
Digoxin (Serum)
Direct Bilirubin (Serum)
Glucose (CSF)
Glucose (Urine)
HbA1c
HDL (Serum)
L-Homocysteine (Serum)
Lactic Acid (CSF)
LDH (Serum)
LDL (Serum)
LP(a) (Serum)
Magnesium (Urine)
Microalbumin (Urine)
Myoglobin (Serum)
NT-proBNP (Serum)
Phosphorus (Urine)
Potassium (Serum)
Potassium (Urine)
Sodium (Serum)
Sodium (Urine)
Total 25-hydroxyvitamin D
Total Bilirubin (Serum)
Total Cholesterol (Serum)
Total Protein (Urine)
Triglyceride (Serum)
Troponin - I (Serum)
UCFP-TP (CSF)
Urea Nitrogen (Urine)
Uric Acid (Urine)
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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