Model Performance Evaluation Program (MPEP)

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Model Performance Evaluation Program (MPEP)

OMB Form Number 0920-0595

Expiration Date: 03/31/2010

Centers for Disease Control and Prevention (CDC)

Model Performance Evaluation Program (MPEP) For HIV Rapid Testing (HIV-RT)

ENROLLMENT FORM

To enroll in the MPEP, please fill in the following form. This information will be entered in the MPEP enrollment database to ensure your laboratory's receipt of mailed performance evaluation panels and CDC published reports of results.

Name of Laboratory: (line1)
Name of Laboratory: (line2)

Laboratory Contact: (check one):

Dr.
Ms.
Mr.
Miss
Mrs.
Rev.
Other

First Name:
Last Name:
Degree:
Title:
Phone #:	Ext:
E-Mail:
Confirm E-Mail:
Fax:
Secondary Phone# (if applicable):	Ext:
Secondary Email (if applicable):
Secondary FAX# (if applicable):

Mailing Address (line 1):
Mailing Address (line2):
City:
State:
Zip Code:

Laboratory Director's Name:
Phone:	Ext:
Email:
Laboratory Supervisor's Name (if applicable):

Please indicate your laboratory type by checking the appropriate category listed below:

Blood Bank [e.g., community, regional, blood/plasma center, Red Cross, privately owned, military, non-hospital blood bank, hospital blood bank (hospital blood bank includes portion of hospital laboratory responsible for blood donor testing]
Hospital [e.g., city, county, district, community, state, regional, military, Veterans Affairs, Federal government (other than military), privately owned, university, HMO/PPO owned and operated, religious-associated]
Health Department [e.g., city, county, state (main, central, or branch), regional, district, national reference laboratory (government affiliated)]
Independent [e.g., commercial, commercial manufacturer of reagents, pharmaceutical laboratory, employee health clinic, reference laboratory (nongovernment affiliated)]
Family Planning Center
Health Maintenance Organization (HMO)
Medical Examiner/Coroner
Physician's Office
Sexually Transmitted Diseases Clinic
Correctional Facility
Counseling and Testing Site
Drug Use Treatment Center
Military [other than blood bank or hospital, e.g. induction center]
Mobile Unit [other than blood donation]
Community Based Organization
Other [e.g., university-associated research, drug screening/toxicology, Federal government research (nonmilitary), organ procurement, privately funded research] Please specify:

Public reporting burden for this collection of information is estimated to average three minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, N.E., MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-0274).

IMPORTANT! If you are enrolling as part of a group of testing sites, check here and contact the MPEP (see contact information below).

Please verify your desire to participate in the MPEP by reading the following prior to submitting the form.

We understand that as partcipants in the Model Peformance Evaluation Program, we will be asked to send the following to CDC:

results of our testing of performance evaluation samples provided by CDC;
information on methods used to test the samples; and
information about the characteristics and testing practices of our laboratory.

IF the performance evaluation samples are to be shipped to an address other than the mailing address listed above, fill in the following information.

(Please note that peformance evaluation samples shipments cannot be delivered to P.O. boxes located in the U.S.):

Hiv Rapid Testing Panel Shipment Contact Person:

(check one): Dr.
Ms.
Mr.
Miss
Mrs.
Rev.
Other

First Name:
Last Name:
Degree:
Title:
Phone #:	Ext:
E-Mail:
Confirm E-Mail:
Fax:

Sample Panel Shipping Facility Name: (line 1)
Sample Panel Shipping Facility Name: (line 2)
Sample Panel Shipping Address: (line 1)
Sample Panel Shipping Address: (line 2)
City:
State:
Zip Code:

If you have questions about the completion of this enrollment information, please contact below:

The MPEP by phone (877)360-8502, email MPEPHIV-RT@cdc.gov, or FAX (404)498-2391
Leigh Vaughan, HIV Rapid Testing Project Coordinator by phone (404)498-2246 or email LVaughan@cdc.gov
Sandra Neal, MPEP Manager by phone (404)498-2238
By writing to:

MPEP Survey Coordinator
Centers for Disease Control and Prevention
Mailstop G-23
1600 Clifton Road, N.E.
Atlanta, Georgia 30329-4018

If you have questions about participants in the MPEP, please contact Sandra Neal, by:

phone (404)498-2238, fax (404)498-2391, or by writing directly to:

Sandra W. Neal, B.S., MT(ASCP), M.S., P.M.P.
MPEP Manager
Model Performance Evaluation Program (MPEP)
Laboratory Practice Evaluation and Genomics Branch
Division of Laboratory Systems, Mailstop G-23
National Preparedness, Detection, and Control of Infectious Diseases
Coordinating Center for Infectious Diseases
Centers for Disease Control and Prevention (CDC)
1600 Clifton Road, N.E.
Atlanta, GA 30329-4018

This page last reviewed: 09/02/2009

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