HIV-1 Antibody Laboratory Information Change form

Model Performance Evaluation Program

Laboratory Information Change Form

MPEP Number: «MPEPNUMT»

Mailing address of laboratory: Shipping address of laboratory:

«MLINE1» «MLINE2» «MLINE3» «MLINE4» «MLINE5» «MLINE6» Phone: «PHONE» Fax: «FAX» E-mail: «EMAIL»

«SLINE1» «SLINE2» «SLINE3» «SLINE4» «SLINE5» «SLINE6»

Laboratory Director: «DIRECTOR»

In the spaces below, please indicate only those changes to be made to the current information listed above:

1. Contact Person: Name: .

Title: .

2. Laboratory Name: .

.

Laboratory Director: .

4a. Mailing address of Laboratory (address to which correspondence should be sent):

Street / PO Box: .

.

City: . State/Province: .

Country: . Postal Code: .

Telephone No.: Extension: .

FAX Number: E-mail: .

4b. Shipping address to which specimens should be mailed (if different from above):

Note: specimens cannot be mailed to PO Boxes.

Street: .

.

City: . State/Province: .

Country: . Postal Code: .

5. Please indicate by checking () all MPEP programs to which these changes should be applied:

HIV-1 antibody HIV Rapid Test

6. Person completing form: ______________________________________________________

7. Today’s Date: _______________

Fax changes to (404) 325-2667, call Constella Group, LLC directly at 1-800-642-6941, or mail using the enclosed pre-addressed envelope to:

CDC MPEP Survey Coordinator

Constella Group, LLC

3 Corporate Boulevard, Suite 600

Atlanta, GA 30329

HIV 0607