Mycobacterium tuberculosis Drug Susceptibility and NTM Testing Performance Evaluation Enrollment Form

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Mycobacterium tuberculosis Drug Susceptibility and NTM Testing Performance Evaluation Enrollment Form

Open to all U.S Laboratories. International is limited to laboratories which have public health responsibilities for tuberculosis drug susceptibility testing and approval by their National Tuberculosis Program.

Enrollment for laboratories outside of the U.S. is restricted to national reference laboratories or selected regional public health laboratories.

Please provide the following contact information:
( * indicates required information)

Name*
Title*
Lab Name*
Street address*
Address (cont.)
City*
State/ Province*
Zip/Postal code*
Country*
Work Phone*
FAX*
E-mail

Please provide the following shipping information (overnight courier), if different from the contact information specified above or if the address specified above is a post office box (PO Box) - isolates cannot be shipped to a PO box

Name
Title
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail

Does your laboratory conduct diagnostic testing for Mycobacterium tuberculosis? *
YesNo
Does your laboratory perform Mycobacterium tuberculosis drug susceptibility testing? *
YesNo
If YES, does your laboratory follow Biosafety Level III practices in performing Mycobacterium tuberculosis susceptibility testing? *
YesNo
Does your laboratory conduct in-house susceptibility testing of non-tuberculous mycobacteria (NTM)? *
YesNo
Which of the following performance evaluation samples would your laboratory like to receive? *
Mtb OnlyNTM OnlyBoth Mtb & NTM
Select the primary classification of your laboratory:*
HospitalIndependentHealth DepartmentOther
If you have any questions please contact us.

This page last reviewed: 11/04/2009

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