VITAL-EQA Enrollment Form International

NCEH DLS Laboratory Quality Assurance Programs

Att 3f. VITAL-EQA EnrollForm Intl.xls

OMB: 0920-1389

Document [xlsx]
Download: xlsx | pdf
Yes Participant Registration Form for VITAL-EQA
Fill all applicable yellow fields from sections 1 - 4.

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx
No










Please fully complete this form and return it to [email protected]
























1. Participant Information for Enrollees


1 Are you a new Enrollee (Yes/No)? If yes, skip to question 3



2



Existing VITA-EQA participants enter your VITAL-EQA Lab ID



3 Enter the EQA year for which you are registering (ex: 2019)



4 Company/Institution:



5 Primary Contact (First and Last Name):



6 Telephone Number:



7 Email:



8 OPTIONAL: Additional or Alternate Email address:














2. VITAL-EQA Analytes



Sample Sets Analyte Will Participate in Spring (April) Round

(Yes/No to all)
Will Participate in
Fall (October) Round

(Yes/No to all)
VITAL-EQA vials contain 1mL of serum each

Is > 1mL needed to conduct 2 measurements per vial?

SEE NOTE BELOW



1 B-Vitamins Set Vitamin B12





2 Folate





3 Iron Indicators Set CRP





4 Ferritin





5 sTfR





6 Fat-Soluble Vitamins Set Retinol





7 25-hydroxy-vitamin D






NOTE:
Due to limited quantities of VITAL-EQA materials, we are unable to send more than one kit per analyte group to participants unless we recently received data demonstrating your need for the multiple sets (i.e. data showing that vials were combined or separate sets were used to conduct the full analysis associated with that panel).
Unfortunately, we are unable to provide back-up vials or replace lost or damaged kits.














3. Shipping Details/Notes/Comments


1 Do you want to receive both Spring and Fall samples together in one shipment (Yes/No)?



2 Can you accept shipments with dry ice (Yes/No)?



3 Can you accept shipments from FedEx (Yes/No)? (CDC will likely cover shipping costs).



4 If FedEx not accepted, provide alternate carrier information (CDC will not cover shipping costs):











Carrier:



Account Number:



5 Are there any special requirements/paperwork needed to clear this shipment (Yes/No)? If yes, describe in section 4.







6 Are there particular days of the week that the shipment should arrive (Yes/No)?







7 If so, please specify which days:



8 Please type your Exact Shipping Address below:



Recipient Name




Your Institution Name




Your Shipping Address


































Your Phone




Your Email



Optional: Broker Information


9 Do you need a customs broker to clear the shipment in your country (Yes/No)? (CDC will not cover broker fees)



10 If so, provide Broker information:





Broker Contact Name




Broker/Company




Broker Address
















Broker Phone




Broker Email














4. Additional Notes/Comments/Documents


1 Please specify all shipping documents you will need to process the shipment:














































2 Additional Comments or Notes:


























Please direct any questions to the VITAL-EQA administrator at [email protected]




















File Typeapplication/vnd.ms-excel
AuthorChaudhary-Webb, Madhulika (CDC/ONDIEH/NCEH)
Last Modified ByNCEH-ATSDR
File Modified2021-11-02
File Created2008-09-22

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