Form 0920-1313 Att5b Test Kit Qs Int Labs (Word) 20221202

Attachment 5b. Test Kit Application and Questions for International Laboratories (Word)

CDC estimates the average public reporting burden for this collection of information as 4 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

First Name [__________]

Last Name [__________]

Institution [__________]

Lab Name (optional) [__________]

Street Address Line 1 [__________]

Street Address Line 2 [__________]

City [__________]

Zip/Postal Code [__________]

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

Email [__________]

Verify Email [__________]

Telephone [__________]

Does your laboratory have the capabilities to handle substances that may be controlled in your region and obtain any necessary import authorizations required to receive these products?

• Yes

• No

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 [___]

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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