IN THIS SECTIONResourcesQC iDOCs – Technical DocumentsQC Value Assignment ProgramSign-up Now to ParticipateFAQsTestimonialsUrinalysis Made Simple Sign-up Now to ParticipatePlease complete the form below and click "submit." Participants must be CLIA certified or certified with an equivalent agency. Facility Name:*Facility Type*Facility TypeLaboratoryManufacturerHospital / ClinicContact Person:*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Domestic Phone Number*International Phone Number*Domestic Fax NumberInternational Fax NumberEmail* Please fill out the information for the person that completed this survey in the spaces below.Name*Title*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country By entering your name here and submitting your laboratory information for our Value Assignment Program, you are authorizing Quantimetrix Corporation to contact you for this purpose. We will not use your information for any other purpose. We will contact you once your information is received. Thank you.Signature:*Analyzer(s) UsedPlease list the analyzer(s) currently used in your laboratory:Please check all assays performed in your lab:ssays performed in your lab 25-hydroxyvitamin D2/25-hydroxyvitamin D3 Alcohol (Serum) Ammonia (Serum) Amylase (Urine) Apolipoprotein A1 (Serum) Apolipoprotein A2 (Serum) Apolipoprotein B (Serum) Apolipoprotein C2 (Serum) Apolipoprotein C3 (Serum) Apolipoprotein E (Serum) Calcium (Urine) Chloride (Serum) Chloride (Urine) CK-MB (Serum) CK, Total (Serum) Creatinine (Urine) CRP (Serum) Digoxin (Serum) Direct Bilirubin (Serum) Glucose (CSF) Glucose (Urine) HbA1c HDL (Serum) L-Homocysteine (Serum) Lactic Acid (CSF) LDH (Serum) LDL (Serum) LP(a) (Serum) Magnesium (Urine) Microalbumin (Urine) Myoglobin (Serum) NT-proBNP (Serum) Phosphorus (Urine) Potassium (Serum) Potassium (Urine) Sodium (Serum) Sodium (Urine) Total 25-hydroxyvitamin D Total Bilirubin (Serum) Total Cholesterol (Serum) Total Protein (Urine) Triglyceride (Serum) Troponin - I (Serum) UCFP-TP (CSF) Urea Nitrogen (Urine) Uric Acid (Urine)CLIA, COLA, DAP, CLIP, ISO CertificationIs your facility certified by any of the above agencies?YesNoIf yes, please complete the following:Date of last inspection:Certification number:We will contact you for a copy of your certification upon receipt of your survey.Is there an internal quality audit program that covers all areas of operation to verify that procedures and policies are being followed to determine the effectiveness of the quality system?YesNoIs there a procedure for receiving, reviewing, handling and storage of samples?YesNoAre calibration records maintained for each piece of equipment or instrument?YesNoType any other questions or considerations.By submitting your data, you agree to the processing of your data in accordance with our Privacy Policy This iframe contains the logic required to handle Ajax powered Gravity Forms.
