CDCModel Performance Evaluation Program (MPEP) Laboratory Change Form

CDC Model Performance Evaluation Program (MPEP) for Retroviral and AIDS-Related Testing

Attachment 8 HIICF_domestic

CDCModel Performance Evaluation Program (MPEP) Laboratory Change Form

OMB: 0920-0274

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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



File Typeapplication/msword
File TitleModel Performance Evaluation Program
Last Modified Bycrodi
File Modified2006-05-04
File Created2003-05-15

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