Application drugtesting for 2014

Form DTL-COA-AF-2007 Republic of the Philippines Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179 URL: http://www.doh.gov.ph/

Application for Accreditation of Drug Testing Laboratory

St. Luke's Medical Center Global City Name of Laboratory1 :____________________________________________________ Address of the Laboratory :____________________________________________________ Usuan 32nd Street No. & Street

Barangay

City/ Municipality

Province

Metro Manila NCR Taguig ____________________________________________________ Region

Telephone/ Fax No.

789 - 7700 Loc. 2074 :____________________________________________________

Name of Head of the Laboratory

Dr. Ma. Cecilia F. Lim :____________________________________________________

Name of Owner Contact No.

St. Luke's Medical Center Global City, Inc. :____________________________________________________ 789 - 7700 :____________________________________________________

Classification According to Ownership : [ ] Government

[ X ] Private

Character

: [ X] Institution-Based

[ ] Free-Standing

Service Capability

: [ X] Screening

[ ] Confirmatory

: [ ] Initial [ ] New [ ] Late Filing [ ] Transfer of Site [ ] Change of Business Name/ Ownership

[ X ] Renewal Accreditation No. 13-0716-13-PIBS-R ____________ JANUARY 1, 2013 Date Issued ________________ Expiry Date _________________ DECEMBER 31, 2013

Status of Application

Checklist of Application Documents Please tick (
) the appropriate boxes under column B or C. Items shaded are not required.

1. 2. 3. 4.

5. 6. 7. 1

A Documents Notarized Application for Accreditation of Drug Testing Laboratory (this form) Letter of Endorsement to the BHFS Director (if filed at CHD) List of Personnel (use attached form) Photocopies of the following: 4.1. Proof of qualification of head of the laboratory, analyst and authorized specimen collector
PRC ID/ PRC Board Certificate, if applicable
PSP Certificate, if applicable
Certificate of Training/ Record of Work Experience 4.2. Proof of employment of head of the laboratory, analyst and authorized specimen collector List of Equipment/ Instrument (use attached form) Duly accomplished Assessment Tool (use attached form) Documentation of Chain of Custody

B For Initial

C For Renewal

The name of laboratory should match both DTI/ SEC Registration and Mayor’s/ Business Permit. Page 1 of 4

Form DTL-COA-AF-2007

8.

9. 10. 11. 12. 13. 14. 15. 16.

A Documents Quality Control Program (for screening laboratory) OR Certification for Quality Standard System by a DOH recognized certifying body (for confirmatory laboratory) Certificate of Proficiency/ Proficiency Testing Result Procedure Manual Contract of Lease (if site is rented) Location Map for the laboratory building Photographs of the exterior and interior of the laboratory Floor Layout with appropriate scale reflecting properly labeled areas to include spatial relationship with adjacent areas if present DTI/ SEC Registration (for private laboratory) OR Issuance or Board Resolution (for government laboratory) Photocopy of DOH Certificate of Accreditation

B For Initial

C For Renewal

Acknowledgement REPUBLIC OF THE PHILIPPINES ) CITY/ MUNICIPALITY OF ______________ ) S.S.

Maria Cecilia F. Lim Single 46 ______________________________, ____________, of legal age, __________, a resident of Civil Status Age Name 1801-A Aguila St., San Miguel, Manila ___________________________________________, after having been sworn in accordance with law hereby depose and Address say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the attached I,

documents required for the Registration and Accreditation of Drug Testing Laboratory pursuant to R.A. 9165 “Comprehensive Dangerous Drugs Act of 2002”.

_________________________ Signature

Before me, this _________day of ______________ 2007 in the City/ Municipality of ________________, Philippines, personally appeared

Owner _____________________________

Community Tax Number _____________________________

Issued at/ on _____________________________

known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2007.

Doc. No. _____________________ Page No. _____________________ Book No. _____________________ Series of _____________________

NOTARY PUBLIC My Commission Expires Dec. 31. 200___

Page 2 of 4

Form DTL-COA-AF-2007

List of Personnel Name of Laboratory :_________________________________________________________________________________________ Address of the Laboratory :_________________________________________________________________________________________

Name

Designation/ Position

Highest Educational Attainment

PRC Reg. No.

Valid From

To

Signature

Page 3 of 4

Form DTL-COA-AF-2007

List of Equipment/ Instrument2 Name of Laboratory :_________________________________________________________________________________________ Address of the Laboratory :_________________________________________________________________________________________

Brand Name & Model

2

Serial No.

Quantity

Date of Purchase

Equipment/ instrument should be present, functional, and owned by laboratory applying for accreditation. Page 4 of 4