Laboratory Personnel Report
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Laboratory Personnel Report Form. This is a California form and can be use in Department Of Health And Human Services Statewide.
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Tags: Laboratory Personnel Report, LA 116, California Statewide, Department Of Health And Human Services
State of California--Health and Human Services Agency California Department of Public Health Laboratory Field Services 850 Marina Bay Parkway, Bldg. P, 1st Floor Richmond, CA 94804-6403 LABORATORY PERSONNEL REPORT Laboratory name State ID number CLIA number Laboratory address (number, street) City State ZIP code Contact person Telephone number ( ) TESTING IN THE FOLLOWING: I OH M RIC M ASY MI U LTT I MC NCPPCO C MHHHYAAOG R UEEETTTME O NMMMOHHPN POSITION(S) HELD EMPLOYEE NAMES Last Name First Name M.I. Director Testing Personnel License or Certificate Number Signature of laboratory director Date I certify that all of the individuals listed above meet the requirements of California Business and Professions Code, Section 1206.5. THIS FORM MAY BE PHOTOCOPIED LAB 116 (7/07) American LegalNet, Inc. www.FormsWorkflow.com LABORATORY PERSONNEL REPORT (Continued) Laboratory name or ID number INSTRUCTIONS: List all personnel (e.g., laboratory assistant, phlebotomist, etc.) who are engaged in collecting and preparing specimens but who are not responsible for test results as "testing personnel." EMPLOYEE NAMES Last Name First Name M.I. From HOURS To DAYS M T W TH F SA SU FUNCTION THIS FORM MAY BE PHOTOCOPIED LAB 116 (7/07) Page 2 American LegalNet, Inc. www.FormsWorkflow.com
