Form 0920-1313 Test Kit Application and Questions for US Laboratories (

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

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Applicant Information

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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)

Academic Research Laboratory

Environmental Laboratory

Government Crime Laboratory

Government Toxicology Laboratory

Private or Public Clinical Laboratory

Other (please specify) ­­­____________________

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

Seized drug sample testing

Post-mortem toxicology sample testing

Workplace drug screening

Newborn drug screening

Drug pharmacology and pharmacokinetics research

Clinical testing for disease diagnosis and treatment or surveillance

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)

< 100

100 - 500

501 - 1000

> 1000

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

Immunoassay

Infrared Spectroscopy

Mass Spectrometry

Nuclear Magnetic Resonance Spectroscopy

Raman Spectroscopy

X-ray Diffraction

Chromatographic Separation

UV/Vis

Other (please specify) ­­­____________________

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

Blood

Urine

• Drug Powders

• Waste Water

Other (please specify) ­­­____________________

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