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Additional Health Department Forms

Forms for Public Health and Environmental Laboratories


Clinical Laboratory Licensure and Proficiency Testing Review
Form # Title PDF/WORD Instruction/ Comments
CL-3 Application for a Clinical Laboratory License (Onsite Testing Only) pdf 73k
doc 403k		 Laboratory Personnel Excel Spread Sheet  
CL-9 Disclosure of Ownership and Control Interest pdf 18k
doc 54k		  
CL-18 Application for a Clinical Laboratory License (Collection Station Only) pdf 13k
doc 43k		  
CL-34 Laboratory Personnel Qualification Appraisal pdf 18k
doc 122k		  
OCC-34 Clinical Laboratory Report of Elevated Levels of Heavy Metals:Lead: In Adults (Greater than 16 Years of Age)Arsenic, Cadmium, Mercury: In Persons of Any Age pdf 15k
doc 48k		  

Blood Bank Licensure and Regulatory Compliance
Form # Title PDF/WORD Instruction/ Comments
CL-8 Blood Bank Annual Statistics (Out of Hospital and Emergency Only Transfusion Facilities) pdf 18k
doc 34k		  
CL-8A Blood Bank Annual Statistics (Hospitals) pdf 38k
doc 199k		  
CL-13 Blood Bank Annual Statistics (Hematopoietic Progenitor Cell Facilities) pdf 15k
doc 29k		  
CL-14 Blood Bank Annual Statistics (Perioperative Autologous Blood Collection and Administration Facilities) pdf 17k
doc 30k		  
CL-16 Application for a Blood Bank License pdf 33k
doc 240k		  
CL-17 Blood Bank Annual Statistics (Umbilical Cord Blood Facilities) pdf 15k
doc 29k		  
CL-21 Error/Accident Report pdf 9k
doc 33k		  
CL-40 Blood Bank Personnel Qualification Appraisal pdf 65k
doc 79k		  
CL-44 Transfusion Reaction Report pdf 8k
doc 31k		  
CL-50 Brokers and Reagent Manufactureres - Annual Statistical Data pdf 50k
doc 59k		  
CL-51 Blood Centers - Annual Statistical Data pdf 29k
doc 129k		  
CL-58 Blood Bank License Fee pdf 8k
doc 26k		  

CLIA Program
Form # Title PDF/WORD Instruction/ Comments
CMS-116 Clinical Laboratory Improvement Amendments (CLIA) Application for Certification  
 		  

Public Health Laboratory Services
Form # Title PDF/WORD Instruction/ Comments
BACT-44 Bacteriological Sample Submittal pdf 18k
doc 95k		  
BACT-109 Request for Identification of Enteric Pathogen, Parasite or Bacteriological Culture pdf 23k
doc 45k		  
LAB-3 Request for Microbiological Testing of Food Sample pdf 16k
doc 36k		  
LAB-5 Request for Testing of Suspected Select Agents and Chain of Custody pdf 25k
doc 66k		  
LAB-7 HIV Test Requistion pdf 8k
doc 8kk		  
SRD-1 Request for Immunological/Isolation Services-Viral Testing Unit pdf 23k
doc 57k		  
SRD-4 Request for Immunological/Isolation Services - Clinical Services Testing Unit pdf 25k
doc 52k		  
VIR-1 Requisition for Viral Serology pdf 22k
doc 39k		 Complete per instructions on form  
VIR-16 Request for Rabies Examination pdf 14k
doc 59k		 Directions/Map to DHSS Lab

Instructions for submission of specimens
pdf 16k
doc 27k  

Environmental and Chemical Laboratory Services
Form # Title PDF/WORD Instruction/ Comments
CHEM-44 Organic and Inorganic Chemistry Sample Submittal pdf 20k
doc 101k		  
Go to Public Health and Environmental Laboratories     Additional Health Department Forms