DOH Forms
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 62k
doc 417k
Instructions for Completing the Application for a Clinical Laboratory License Form
pdf 28k
doc 41k

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
 
IEM-15 Order form for Initial Newborn Screening Request (IEM-1) Forms pdf 8k
doc 27k
 
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
 
LAB-10 Request for Quantiferon-TB Gold
Test In-Tube Method (QFT-IT)
pdf 14k
doc 49k
 
LAB-46 Chain of Custudy Shipping Log pdf 10k
doc 36k
 
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 19k
doc 41k  

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