Enrollment form

Model Performance Evaluation Program for Mycobacterium tuberculosis and

Non-tuberculous Mycobacteria Drug Susceptibility Testing Program (MTB/NTM DST)

Enrollment Form

Open to all U.S. and qualifying International Laboratories

Enrollment for laboratories outside of the U.S. is restricted to National Reference laboratories or selected regional public health laboratories.

Please provide the following contact information: (* indicates required information)

Name* _______________________________________

Title* _______________________________________

Lab Name* _______________________________________

Street address* _______________________________________

Address (cont.) _______________________________________

City* ____________________ State/Province* _____________________

Zip/Postal code* ____________________ Country* ___________________________

Work Phone* ____________________ FAX* ______________________________

E-mail _______________________________________

Please provide the following shipping information (overnight courier), if different from the contact information specified above or if the address specified above is a post office box (PO Box) - isolates cannot be shipped to a P.O. Box

Name _______________________________________

Title _______________________________________

Street address _______________________________________

Address (cont.) _______________________________________

City* ____________________ State/Province* _____________________

Zip/Postal code* ____________________ Country* ___________________________

Work Phone* ____________________ FAX* ______________________________

E-mail _______________________________________

Public reporting of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0600)

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1) Does your laboratory conduct diagnostic testing for Mycobacterium tuberculosis? *
Yes No

2) Does your laboratory perform Mycobacterium tuberculosis drug susceptibility testing? *
Yes No

If YES, does your laboratory follow Biosafety Level 3 practices in performing Mycobacterium tuberculosis susceptibility testing? *
Yes   No

4) Does your laboratory conduct onsite susceptibility testing of NTM? *
Yes No

5) Which of the following performance evaluation samples would your laboratory like to receive? *
M. tb only        NTM only      Both M. tb & NTM

6) Select the primary classification of your laboratory:*
Hospital    Independent   Health Department    Other

Laboratories Outside of the United States please answer the following:

7) Does your laboratory function as a National M. tb reference laboratory

Yes No

8) Is your laboratory part of a national M. tb susceptibility testing network?

Yes No

9) Does your country have any restrictions regarding the transport/receipt of infectious agents which may require obtaining an important permit?

Yes No

IF YES, your laboratory will be responsible for obtaining this permit and forwarding a copy to us for our use.

To contact use:

Email: MTBNTM [email protected]

Call: Dr. Angela Ragin 404 498-2241