ࡱ> q Z 3bjbjt+t+ "AA{]8?@'  ZzT&&&&&&&$)z+J&z  zz&Hz<&z&V_&@&bA4(2yMd& New Jersey Department of Health Clinical Laboratory Improvement Services PO Box 361 Trenton, NJ 08625-0361Application for Clinical laboratory license (clia waived tests only)Calendar Year  FORMTEXT       FORMCHECKBOX  Initial ($200 Fee)  FORMCHECKBOX  Renewal ($200 Fee)For State Use OnlyDate ReceivedReceived ByCheck/E-Pmt. Rec dApproved By LABORATORY INFORMATION Name of Laboratory  FORMTEXT      NJ CLIS ID Number (7 digit number)  FORMTEXT      Laboratory Address (Street Address/PO Box)  FORMTEXT      CLIA Number  FORMTEXT      (City, State, Zip Code)  FORMTEXT      Facility Type (Select one)  FORMCHECKBOX  Physician Office Laboratory  FORMCHECKBOX  School  FORMCHECKBOX  City  FORMCHECKBOX  County  FORMCHECKBOX  Home Health Agency  FORMCHECKBOX  Pharmacy Associated Clinic  FORMCHECKBOX  Health Screening (incl. Mobile)  FORMCHECKBOX  Other:  FORMTEXT ____________Mailing Address [where License(s) should be mailed]  FORMTEXT      (City, State, Zip Code)  FORMTEXT      Laboratory Telephone Number  FORMTEXT      Laboratory Fax Number  FORMTEXT      Name of Contact Person  FORMTEXT      Contact Telephone No.  FORMTEXT      Contact Email Address  FORMTEXT      Normal Hours of Laboratory Operation (indicate specific hours EACH day):Monday:  FORMTEXT      Tuesday:  FORMTEXT      Wednesday:  FORMTEXT      Thursday:  FORMTEXT      Friday:  FORMTEXT      Saturday:  FORMTEXT      Sunday:  FORMTEXT      LABORATORY director INFORMATIONName of Laboratory Director  FORMTEXT      State Medical License Number  FORMTEXT      Laboratory Director s Degree  FORMTEXT      Telephone No.  FORMTEXT      Email Address  FORMTEXT      Laboratory Director s Time on PremisesMonday:  FORMTEXT      Tuesday:  FORMTEXT      Wednesday:  FORMTEXT      Thursday:  FORMTEXT      Friday:  FORMTEXT      Saturday:  FORMTEXT      Sunday:  FORMTEXT      primary general supervisor INFORMATIONName of Primary General Supervisor  FORMTEXT      Primary General Supervisor s Degree  FORMTEXT      Telephone No.  FORMTEXT      Email Address  FORMTEXT      Primary General Supervisor s Time on PremisesMonday:  FORMTEXT      Tuesday:  FORMTEXT      Wednesday:  FORMTEXT      Thursday:  FORMTEXT      Friday:  FORMTEXT      Saturday:  FORMTEXT      Sunday:  FORMTEXT      ownership INFORMATIONName of Owner/Authorized Agent  FORMTEXT      EIN Federal Tax ID  FORMTEXT      Address (Street Address/PO Box, City, State, Zip Code)  FORMTEXT      Telephone Number  FORMTEXT      Type of Entity (Select one)  FORMCHECKBOX  Individual  FORMCHECKBOX  Partnership  FORMCHECKBOX  Corporation  FORMCHECKBOX  Non-ProfitGovernment Entity (Select one)  FORMCHECKBOX  State  FORMCHECKBOX  County  FORMCHECKBOX  MunicipalLIST OF CLIA WAIVED TESTS AND NJ STATE WAIVED TESTS PERFORMEDSelect [  FORMCHECKBOX  ] or Add CLIA-Waived (including NJ State-Waived) Instrument or Test KitName of Instrument or Kit ManufacturerNumber of Tests PerformedAnnually FORMCHECKBOX  Adenovirus FORMTEXT       FORMTEXT       FORMCHECKBOX  Chemistry Panel FORMTEXT       FORMTEXT       FORMCHECKBOX  ESR (Non-Automated) FORMTEXT       FORMTEXT       FORMCHECKBOX  Fecal Occult Blood FORMTEXT       FORMTEXT       FORMCHECKBOX  Hemoglobin FORMTEXT       FORMTEXT       FORMCHECKBOX  Hemoglobin AIC FORMTEXT       FORMTEXT       FORMCHECKBOX  Lipid Panel FORMTEXT       FORMTEXT       FORMCHECKBOX  MMP-9 FORMTEXT       FORMTEXT       FORMCHECKBOX  Prothrombin Time (PT) and/or INR FORMTEXT       FORMTEXT       FORMCHECKBOX  Rapid Flu FORMTEXT       FORMTEXT       FORMCHECKBOX  Rapid Group A Strep FORMTEXT       FORMTEXT       FORMCHECKBOX  Rapid HCV FORMTEXT       FORMTEXT       FORMCHECKBOX  Rapid HIV FORMTEXT       FORMTEXT       FORMCHECKBOX  Rapid Mono FORMTEXT       FORMTEXT       FORMCHECKBOX  Rapid RSV FORMTEXT       FORMTEXT       FORMCHECKBOX  Tear Osmolarity FORMTEXT       FORMTEXT       FORMCHECKBOX  Urine Dipstick (Non-Automated) FORMTEXT       FORMTEXT       FORMCHECKBOX  Urine Drug Screening Test Cup FORMTEXT       FORMTEXT       FORMCHECKBOX  Urine Pregnancy FORMTEXT       FORMTEXT       FORMCHECKBOX  Urine Reagent Strip (Automated) FORMTEXT       FORMTEXT       FORMCHECKBOX  Whole Blood Glucose FORMTEXT       FORMTEXT       FORMCHECKBOX  Whole Blood Lead FORMTEXT       FORMTEXT      ADDITIONAL TESTS FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Total Annual Test Volume: FORMTEXT       PROFICIENCY TESTING PROVIDER(S)Name of Proficiency Testing Provider(s)  FORMTEXT       ATTESTATIONI, the undersigned, certify that all the information given on this application and on the accompanying attachments is true, correct, and complete as of this date and that notification, by certified mail, of any change(s) will be made with 14 days of such change(s). 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