State of California--Health and Human Services Agency LABORATORY TESTING DECLARATION Name of laboratory (as listed on CLIA certificate) Laboratory location CLIA number Calif. Dept. of Public Health Laboratory Field Services 850 Marina Bay Parkway, Bldg. P, 1st Floor Richmond, CA 94804-6403 Check and name all tests (by manufacturer and equipment) which are performed in your laboratory and indicate the annual volume of tests performed by subspecialty. Attach separate page if additional space is needed. Waived tests only Physician performed microscopy procedures only 010 Histocompatibility__________________________________________ Annual Volume _______________ 110 Bacteriology Gram stain ____________________________________________ Direct antigen__________________________________________ Limited identification ____________________________________ Throat _____________________________________________ Urine ______________________________________________ G.C._______________________________________________ ID genus and species ___________________________________ Susceptibility testing ____________________________________ C. difficile Ag __________________________________________ Molecular diagnostics ___________________________________ Annual Volume _______________ 115 Mycobacteriology Acid fast stain__________________________________________ ID acid fast____________________________________________ ID and/or susceptibility for M.T.B. __________________________ ID and susceptibility for all acid fast ________________________ Molecular diagnostics ___________________________________ Annual Volume _______________ 120 Mycology ID yeast and/or dermatophytes ____________________________ ID genus______________________________________________ ID genus and species ___________________________________ Annual Volume _______________ 130 Parasitology Wet mounts and/or pinworms preparation____________________ ID conc. and/or stain ____________________________________ Annual Volume _______________ 140 Virology Direct antigen__________________________________________ ID ___________________________________________________ Molecular diagnostics ___________________________________ Annual Volume _______________ 210 Syphilis serology FTA­ABS _____________________________________________ RPR _________________________________________________ RST _________________________________________________ VDRL ________________________________________________ MHA­TP _____________________________________________ Annual Volume _______________ 220 General immunology Alpha­1 antitrypsin _____________________________________ Alpha­fetoprotein_______________________________________ Antihuman immunodeficiency virus (HIV) ____________________ Antinuclear antibody ____________________________________ Antistreptolysin O_______________________________________ Complement C3 ________________________________________ Complement C4 ________________________________________ CRP _________________________________________________ Hepatitis A antibody _____________________________________ Hepatitis B core Ab _____________________________________ HBsAb _______________________________________________ HBsAg _______________________________________________ HBeAg _______________________________________________ Hepatitis C Ab _________________________________________ H. pylori Ab ___________________________________________ IgA __________________________________________________ IgE __________________________________________________ IgG __________________________________________________ IgM __________________________________________________ Infectious mononucleosis_________________________________ Rheumatoid factor ______________________________________ Rubella_______________________________________________ Annual Volume _______________ LAB 144 A (7/07) 310 Routine chemistry Alanine aminotransferase (ALT/SGPT) ______________________ Albumin ______________________________________________ Alkaline phosphatase____________________________________ Ammonia _____________________________________________ Amylase ______________________________________________ Aspartate aminotransferase (AST/SGOT) ____________________ Bilirubin, total __________________________________________ Blood gases: pH pCO2 pO2 ___________________ Calcium ______________________________________________ CEA _________________________________________________ Chloride ______________________________________________ Cholesterol, high density lipoprotein (HDL) ___________________ Cholesterol, total _______________________________________ CO2 _________________________________________________ Creatine kinase ________________________________________ Creatine kinase, iso and CKMB____________________________ Creatinine_____________________________________________ Cryoglobulin ___________________________________________ Ferritin _______________________________________________ Folate ________________________________________________ Gamma GT ___________________________________________ Glucose, serum ________________________________________ Glucose, whole blood ___________________________________ Iron, total _____________________________________________ TIBC_________________________________________________ Lactate dehydrogenase (LDH)_____________________________ LDH isoenzymes _______________________________________ Lactic acid ____________________________________________ Magnesium ___________________________________________ Osmolality ____________________________________________ Phosphorus ___________________________________________ Potassium ____________________________________________ PSA _________________________________________________ Sodium_______________________________________________ Total protein ___________________________________________ Triglycerides___________________________________________ Troponin--1 ___________________________________________ Urea nitrogen __________________________________________ Uric acid ______________________________________________ Vitamin B-12 __________________________________________ Annual Volume _______________ 320 Urinalysis Dipsticks______________________________________________ Microscopy____________________________________________ Annual Volume _______________ 330 Endocrinology Cortisol_______________________________________________ Estradiol ______________________________________________ Estriol ________________________________________________ Free thyro