"Laboratory Personnel Report" - Connecticut

Laboratory Personnel Report is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

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Download "Laboratory Personnel Report" - Connecticut

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LABORATORY PERSONNEL REPORT
STATE OF CONNECTICUT, DEPARTMENT OF PUBLIC HEALTH
DIVISION OF HEALTH SYSTEMS REGULATION
MS#12HSR, P.O. BOX 340308, HARTFORD, CT 06134-0308
LABORATORY NAME:
CONNECTICUT LICENSE NO:
Independent: CL
-
LABORATORY ADDRESS:
Hospital: HP-
LABORATORY DIRECTOR:
TELEPHONE NO.:
For State Use Only. Surveyor Name:
Survey Date:
List all technical personnel employed by the laboratory, including the director (D), clinical consultant (CC),
technical consultant (TC) (Moderate), technical supervisor (TS) (High), general supervisor (GS) (High), and
testing personnel (TP).
POSITION
TEST
State use only.
EMPLOYEE NAME
HELD
DEGREE
COMPLEXITY
SHIFT
Meets Personnel
D, CC, TC, TS,
Qualification
Last Name
First Name
GS, TP
Moderate/High
1, 2, 3
Standards: 19a-36-D__
Signature of Laboratory Director:
Date:
________________________________________________________
_________________________
LABORATORY PERSONNEL REPORT
STATE OF CONNECTICUT, DEPARTMENT OF PUBLIC HEALTH
DIVISION OF HEALTH SYSTEMS REGULATION
MS#12HSR, P.O. BOX 340308, HARTFORD, CT 06134-0308
LABORATORY NAME:
CONNECTICUT LICENSE NO:
Independent: CL
-
LABORATORY ADDRESS:
Hospital: HP-
LABORATORY DIRECTOR:
TELEPHONE NO.:
For State Use Only. Surveyor Name:
Survey Date:
List all technical personnel employed by the laboratory, including the director (D), clinical consultant (CC),
technical consultant (TC) (Moderate), technical supervisor (TS) (High), general supervisor (GS) (High), and
testing personnel (TP).
POSITION
TEST
State use only.
EMPLOYEE NAME
HELD
DEGREE
COMPLEXITY
SHIFT
Meets Personnel
D, CC, TC, TS,
Qualification
Last Name
First Name
GS, TP
Moderate/High
1, 2, 3
Standards: 19a-36-D__
Signature of Laboratory Director:
Date:
________________________________________________________
_________________________