2015 hbv eqa result form (1)

7/24/2019 2015 HBV EQA Result Form (1)

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2015 EQAS SEROLOGY

LABORATORY REPORT FORM

Laboratory Code ________

General Information:

Name of Testing Laboratory: ____________________________________________________________Address: ____________________________________________________________________________Telephone number: __________________________ Fax No: __________________________________Email Address of Contact Person: ________________________________________________________

Name of Pathologist: __________________________________________________________________

Name of edical Technologist !ho performed the test for:Anti"#$% & ' ( test : _____________________ P)C Number: __________ #$% Prof*Cert* No*+Expiry:_________#,sAg Test: ___________________________ P)C Number: __________Anti"#C% Test: _________________________ P)C Number: __________

-ate sample+s recei.ed: _____________________

/ere samples recei.ed in good condition01 2 3es

1 2 No4 if no gi.e comment 1attested by courier2 ________________________________

Demographics1Laboratory5s location by region2 : ________________ 6ip Code: ___________

Type of Laboratory: 1chec7 item21 2 Pri.ate #ospital based 1 2 Free standing1not connected to hospital+clinic21 2 8o.ernment #ospital based 1 2 Clinic based

1 2 9thers 1i*e* )#4 C#94 ;#C4 N894 T,"-9T;24 specify _____________________________________

Facility:Centrifuge: 1 2 a.ailable 1 2 not a.ailable 1 2 a.ailable but $f No4 gi.e reason for failure to submit resultthrough the system:

________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________NOTE: INCOMPLETE FILLED UP FORMS ARE NOT ACCEPTABLE

ALL participants, are required t encde t!eir resu"ts t OAS#S$ Fai"ure t encde%eans n resu"t su&%itted and des nt 'arrant t!e issuance ( Certi(icate (Participatin (r t!e current Test E)ent$

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Republic of the PhilippinesDepartment of Health

SAN LAZARO HOSPITAL

National Refeen!e La"oato# fo HI$ % AI&S' He(atiti) B * +' an, S#(-ili)ST& % AI&S +oo(eati.e +ental La"oato#

Quiricada St., Sta. Cruz, ManilaTel Nos !"#$%#&'()$*+$( Telea- !"#$%&&/&&

0ebsite saccl.doh.1o2.ph 3mail nrlslhsaccl45ahoo.com.ph


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HB)A/ Te)tin/LA!RAT!R" R#$!RT F!R%

Laboratory Code: __________

RA$ID T#&T 'IT R#&(LT& )ICT* Dot lot* Agglutination* etc+

Information about the test run)s+

(use separate sheet if test is performed more than once using other method)

Full Commercial Name of Assay sed: _____________________________________________________

,rand and anufacturer: _______________________________Address:__________________________

Name of -istributor+ $mporter :________________Address +Tel ?:_______________________________

Assay Lot No: _____________________________Expiration -ate: _____________________________

-ate ;ample tested: ____________________

Results from test run)s+

;ample $- )E;LT

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$ncNote: For Rapid tests, encode one run result only in OASS

%ICR!TIT#R I%%(,!A&&A" R#&(LT&)&emi-Automated+Information about the test run)s+

(use separate sheet if test is performed more than once using other method)


,rand and anufacturer: __________________________Address:_________________________________

Name of -istributor+ $mporter :____________________ __Address +Tel ?:___________________________

Assay Lot No: ___________________________________Expiration -ate:__________________________

Name+odel of e@uipment 1E$A )eader2 used______________________ anufacturer______________

-ate sample tested: &strun __________________> (ndrun _______________________

;ample $- &strun 1;+C9 ratio2 (ndrun in duplicate1;+C9 ratio2 Assay $nterpretation

9-1A2

Cut9ff1,2

;+C91A,2

9-1A2Cut9ff

1,2;+C9 1A,2

-up & -up ( -up & -up (

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

Note: INC inconclusive

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Fully-A(T!%AT#D I%%(,!A&&A" R#&(LT&

Information about the test run)s+(use separate sheet if test is performed more than once using other method)


anufacturer: _____________________________Address:____________________________________

Name of -istributor+ $mporter :________________Address +Tel ?:_______________________________Assay Lot No: ___________________________________Expiration -ate:__________________________

Name+odel of e@uipment used _______________________ _____ anufacturer __________________

-ate sample tested> &strun _______________________> (ndrun _______________________

Results from test run)s+

;ample $- &strun1 2 ;+C9 1 2;+N 1 2m$+ml1 2 9thers 1Pls specify2 _________

(ndrun in duplicate1;+C9 ratio21 2 ;+C9 1 2;+N 1 2m$+ml1 2 9thers 1Pls specify2 _________

Assay $nterpretation

-up & -up (

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

1 2) 1 2N) 1 2$nc

Note: INC inconclusive

Fre.uency of use of internal /C ) using 0no1n )-+ and )2+ e3cluding ICT controls in 4sAg test de5ice+* e5ery 1 2 test run 1 2 ne! operator 1 2 ne! lot1 2 daily 1 2 !ee7ly 1 2 monthly1 2 shift 1 2 after certain number of tests 1 2 others __________

Do you use other .uality control samples )not included in 4sAg test 0it+ in your regular testing6) +,o ) + if yes complete information belo1

;ource: 1 2 $n"house4 prepared by o!n laboratory1 2 Commercial4 pls specify name: ________________________

Do you do 4sAg confirmatory test6 ) +yes ) +no$f yes4 $ndicate brand+manufacturer of reagent used ________________________________________$f no4 !hat do you do !ith initially reacti.e results0 1 2 report initial test result 1 2 refer 4 to !hom0

1 2 other referral laboratory 1 2 N)L

1 2 repeat testing 1 2 using same 7it4 then report result

1 2 using another 7it4 different principle4 report 1 2 other

Name of person completing these #,sAg test result forms: ____________________________________Name+ -esignation 1;ign o.er printed name2-ate:_____________________

;uper.isor: __________________________________

Name+ -esignation 1;ign o.er printed name2 -ate: _________________

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2015 hbv eqa result form (1)

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