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 Type | application/msword |
| File Title | Model Performance Evaluation Program |
| Last Modified By | crodi |
| File Modified | 2006-05-04 |
| File Created | 2003-05-15 |