State of California—Health and Human Services Agency California Department of Public Health Laboratory Field Services APPLICATION FOR APPROVAL TO PERFORM HIV TESTS Complete and return this form if HIV testing is to be done at the address indicated. A separate application must be made for each testing location. PLEASE SUBMIT PROOF OF ENROLLMENT IN AN APPROVED PROFICIENCY TESTING PROGRAM. A new application must be filed if there is a change in the laboratory director of this facility or in the USFDA approved test(s) used. Send to: California Department of Public Health Laboratory Field Services 850 Marina Bay Parkway, Bldg. P, 1st Floor Richmond, CA 94804-6403 I. APPLICATION TYPE (Check One) � NEW APPLICATION � UPDATE APPLICATION: � Change of address � Change of director � Change/addition of testing kit II. GENERAL INFORMATION (Please Type or Print) CLIA identification number California state laboratory identification number US FDA license number County State Name of facility Laboratory address (number, street) City ZIP code Telephone number (include area code) FAX number (include area code) Name of laboratory director Name and title of contact person (if other than laboratory director) Proficiency testing agency Proficiency testing agency identification number III. TYPE OF FACILITY � Blood bank � Clinical laboratory � Public health laboratory � Other (specify) ____________________________________________ IV. APPROVAL REQUESTED (Please Type or Print) US FDA Screening Test US FDA Confirmation Test Complete if Confirmation Test is Not Performed HIV Monitoring Test Manufacturer Manufacturer Testing laboratory Manufacturer Method Method Method/manufacturer Method Remarks: I declare that the foregoing statements are true and correct; that I have read and understand the provisions that apply. _________________________________________________________________________ _______________________ Signature of laboratory director Date Department Use Only LAB 165 (5/07) Copies to: � Submitter � L.A. Office � Richmond Office American LegalNet, Inc. www.FormsWorkflow.com