0920-1313 Att5a Test Kit Applctn Qs US Labs (Word) 20221202

[NCEH] Distribution of Traceable Opioid Material* Kits (TOM Kits*) across U.S. Laboratories

Att5a Test Kit Applctn Qs US Labs (Word) 20221202

OMB: 0920-1313

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Attachment 5a. Test Kit Application and Questions for US Laboratories (Word)


CDC estimates the average public reporting burden for this collection of information as 6 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1313).

OMB No. 0920-1313
Exp. Date 12/31/2022

Top of Form

Applicant Information

Top of Form

First Name [__________]

Last Name [__________]

Institution [__________]

Lab Name (optional) [__________]

Street Address Line 1 [__________]

Street Address Line 2 [__________]

City [__________]

State [__________] (dropdown) * This field is required

Zip/Postal Code [__________]

Email [__________]

Verify Email [__________]

Telephone [__________]

Does your laboratory have a current DEA registration to handle scheduled substances?

[YES/NO] * This field is required

Testing Information


1. Which test kit(s) are you requesting / have you previously received? (provide quantity requested)

Fentanyl Analog Screening (FAS) Quantity [___]

FAS Version 1 Quantity [___]

FAS Version 2 and 3 Quantity [___]

FAS Version 4 Quantity [___]

Emergent Drug Panel (EDP) Quantity [___]


2. Which of the following best describes your laboratory? (Select only one)

Shape1 Academic Research Laboratory

Shape2 Environmental Laboratory

Shape3 Government Crime Laboratory

Shape4 Government Toxicology Laboratory

Shape5 Private or Public Clinical Laboratory

Shape6 Other (please specify) ­­­____________________


3. Which of the following tests or services are performed by your laboratory? (Select all that apply)

Shape7 Seized drug sample testing

Shape8 Post-mortem toxicology sample testing

Shape9 Workplace drug screening

Shape10 Newborn drug screening

Shape11 Drug pharmacology and pharmacokinetics research

Shape12 Clinical testing for disease diagnosis and treatment or surveillance

Shape13 Other (please specify) ­­­____________________


4. Which of the following drug categories does your laboratory test for? (Select all that apply)

Opioids

Synthetic Cannabinoids

Stimulants and Hallucinogens

Benzodiazepines


5. On average, how many opioid, synthetic cannabinoid, stimulant, hallucinogen, or benzodiazepine-related samples does your laboratory analyze on a weekly basis? (Select only one)

Shape14 < 100

Shape15 100 - 500

Shape16 501 - 1000

Shape17 > 1000


6. Which of the following analytical techniques do you perform in your laboratory? (Select all that apply)

Shape18 Immunoassay

Shape19 Infrared Spectroscopy

Shape20 Mass Spectrometry

Shape21 Nuclear Magnetic Resonance Spectroscopy

Shape22 Raman Spectroscopy

Shape23 X-ray Diffraction

Shape24 Chromatographic Separation

Shape25 UV/Vis

Shape26 Other (please specify) ­­­____________________


7. Which sample matrices does your laboratory analyze? (Select all that apply)

Shape27 Blood

Shape28 Urine

  • Drug Powders

  • Waste Water

Shape29 Other (please specify) ­­­____________________


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorNCEH/ATSDR Office of Science
File Modified0000-00-00
File Created2023-09-02

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