"Application for Blood Collection Facility Certification" - Connecticut

Application for Blood Collection Facility Certification is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on February 1, 2015;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
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Download "Application for Blood Collection Facility Certification" - Connecticut

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CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
HEALTHCARE SYSTEMS BRANCH & HEALTH SYSTEMSS REGULATION
410 CAPITOL AVE., MS # 12FLIS, P.O. BOX 340308, HARTFORD, CT 06134-0308.
TEL: 860-509-7400
FAX: 860-509-7535
APPLICATION FOR BLOOD COLLECTION FACILITY CERTIFICATION
Office Use Only
Date Received: ………………………………………………..
Approved: YES
NO
DS No. …………………………………………………………….
Date of Approval: ………………………………………
1. APPLICATION DATE:
(Year)
(Month)
(Day)
2. LABORATORY IDENTIFICATION:
A. Name of Laboratory:
B. Address (Number, Street, City, State, Zip code):
C. Connecticut License Number (CL#
) or Registration Number (HP#
)
D. Other blood collection facilities (if any) attached to this CL # or HP#:
1
2
3
4
5
Note: Each licensed laboratory shall be limited to six (6) blood collection facilities
3. BLOOD COLLECTION FACILITY INFORMATION:
A. Name of Facility:
B. Address (Number, Street, City, State, Zip code):
Fax #:
C. Telephone #:
D. Days and Hours of Operation:
Sunday
Monday
Tuesday
Wednesday Thursday
Friday
Saturday
From:
To:
E. Application for:
Initial Approval
Change of Address
Change of Director
Other
Specify:
1
CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
HEALTHCARE SYSTEMS BRANCH & HEALTH SYSTEMSS REGULATION
410 CAPITOL AVE., MS # 12FLIS, P.O. BOX 340308, HARTFORD, CT 06134-0308.
TEL: 860-509-7400
FAX: 860-509-7535
APPLICATION FOR BLOOD COLLECTION FACILITY CERTIFICATION
Office Use Only
Date Received: ………………………………………………..
Approved: YES
NO
DS No. …………………………………………………………….
Date of Approval: ………………………………………
1. APPLICATION DATE:
(Year)
(Month)
(Day)
2. LABORATORY IDENTIFICATION:
A. Name of Laboratory:
B. Address (Number, Street, City, State, Zip code):
C. Connecticut License Number (CL#
) or Registration Number (HP#
)
D. Other blood collection facilities (if any) attached to this CL # or HP#:
1
2
3
4
5
Note: Each licensed laboratory shall be limited to six (6) blood collection facilities
3. BLOOD COLLECTION FACILITY INFORMATION:
A. Name of Facility:
B. Address (Number, Street, City, State, Zip code):
Fax #:
C. Telephone #:
D. Days and Hours of Operation:
Sunday
Monday
Tuesday
Wednesday Thursday
Friday
Saturday
From:
To:
E. Application for:
Initial Approval
Change of Address
Change of Director
Other
Specify:
1
4. PERSONNEL:
A. Name of Director:
B. Name of Supervisor:
C. Name of Phlebotomist(s)
D. Name of Physician called in the event of an
emergency:
5. INSPECTION:
A. The blood collection facility must be inspected by representative(s) of the Department of Public
Health, Division of Health Systems Regulations and approved prior to operation. The blood
collection facility will be ready for inspection by the following date.
(Month)
(Day)
(Year)
B. The blood collection facility is an extension of the laboratory to which it is attached. The
director/supervisor who is responsible for the blood collection facility must be present at the
initial inspection.
6. CONTRACT DISCLOSURE:
Copies of any contractual relationships, written or oral, with any practitioner using the services of
the laboratory must be included with this application. Please refer to General Statutes, Title 19a,
Chapter 368a, Section 19a-309(c) and Public Health Code Regulations, Section 19a-36-D36.
A. Does the laboratory have contractual relationships with practitioners who use the services of
the drawing station? i.e. Facility is within a physician’s office. Please check one below.
YES
NO
B. If yes, copy of the contract is enclosed: (check one)
YES
NO
7. CERTIFICATION:
I hereby certify that all information is true and correct.
…………………………………………………………………………………..
…………………………………………………
Signature of Director
Date
Name of Director (Print or Type):
Note: Blood collection facilities shall be identified by signs and advertising in a manner which will not suggest that the facility is a laboratory
Rev: 02/2015
2
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