Form LAB116 OS "Laboratory Personnel Report - out-Of-State Laboratory" - California

What Is Form LAB116 OS?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2007;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LAB116 OS by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form LAB116 OS "Laboratory Personnel Report - out-Of-State Laboratory" - California

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State of California—Health and Human Services Agency
California Department of Public Health
Laboratory Field Services
850 Marina Bay Parkway,
LABORATORY PERSONNEL REPORT
Bldg. P, 1st Floor
Out-of-State Laboratory
Richmond, CA 94804-6403
Laboratory name
CLIA number
Laboratory address (number, street)
City
State
ZIP code
Contact person
Telephone number
(
)
INSTRUCTIONS: List laboratory director(s), all personnel performing tests, and all personnel responsible for test performance. Mark “M” for
moderate complexity tests and “H” for high complexity tests.
DIRECTOR AND/OR PERSONNEL TESTING IN THE FOLLOWING
I
M
O
H
D
M
R
I
C
I
U
A
S
Y
R
M
I
N
L
T
T
E
I
M
C
H
O
C
P
P
C
O
C
C
M
H
E
H
Y
A
A
O
G
LICENSE OR
T
R
U
E
M
E
T
T
T
M
E
PERSONNEL NAMES
CERTIFICATE
O
O
N
M
A
M
O
H
H
P
N
Last Name
First Name
M.I.
Type*
Number
R
M H M H
M H M H M H M H M H M H M H M H
*Include copy of license or certificate for each person.
THIS FORM MAY BE PHOTOCOPIED
LAB 116 OS (7/07)
State of California—Health and Human Services Agency
California Department of Public Health
Laboratory Field Services
850 Marina Bay Parkway,
LABORATORY PERSONNEL REPORT
Bldg. P, 1st Floor
Out-of-State Laboratory
Richmond, CA 94804-6403
Laboratory name
CLIA number
Laboratory address (number, street)
City
State
ZIP code
Contact person
Telephone number
(
)
INSTRUCTIONS: List laboratory director(s), all personnel performing tests, and all personnel responsible for test performance. Mark “M” for
moderate complexity tests and “H” for high complexity tests.
DIRECTOR AND/OR PERSONNEL TESTING IN THE FOLLOWING
I
M
O
H
D
M
R
I
C
I
U
A
S
Y
R
M
I
N
L
T
T
E
I
M
C
H
O
C
P
P
C
O
C
C
M
H
E
H
Y
A
A
O
G
LICENSE OR
T
R
U
E
M
E
T
T
T
M
E
PERSONNEL NAMES
CERTIFICATE
O
O
N
M
A
M
O
H
H
P
N
Last Name
First Name
M.I.
Type*
Number
R
M H M H
M H M H M H M H M H M H M H M H
*Include copy of license or certificate for each person.
THIS FORM MAY BE PHOTOCOPIED
LAB 116 OS (7/07)