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 42k

Laboratory Personnel Excel Spread Sheet  
CL-9 Disclosure of Ownership and Control Interest pdf 16k
doc 55k
 
CL-18 Application for a Clinical Laboratory License (Collection Station Only) pdf 13k
doc 43k
 
CL-34 Laboratory Personnel Qualification Appraisal pdf 18k
doc 103k
 
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 37k
doc 246k
 
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 11k
doc 28k
 

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 96k
Instructions for Completing Sample Submittal Forms
pdf 11k
doc 26k  
BACT-109 Request for Bacterial or Viral Culture or Parasite Identification pdf 12k
doc 42k
 
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
 
SRD-1 Request for Immunological/Isolation Services-Viral Testing Unit pdf 23k
doc 53k
 
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 19k
doc 100k
Instructions for Completing Sample Submittal Forms
pdf 11k
doc 26k  
CTL-1 Medicinal Marijuana Testing Laboratories Specimen Submittal pdf 13k
doc 41k
Instructions for Completing Sample Submittal Forms
pdf 8k
doc 23k  
Go to Public Health and Environmental Laboratories     Additional Health Department Forms