FORM CMS-209 (09/) DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0151 LABORATORY PERSONNEL REPORT (CLIA) (For moderate and high complexity testing) 1.LABORATORY NAMEAmerican LegalNet, Inc. www.FormsWorkFlow.com Check ()here if additional space is needed to list all technical personnel. Copy this page and attach continuation sheet(s) to the original form.READ THE FOLLOWING CAREFULLY BEFORE SIGNINGStatement or Entities Generally: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes false, fictitious orfraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false,fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.(U.S. Code, Title 18, Sec. 1001)CERTIFICATION: I CERTIFY THAT ALL OF THE INDIVIDUALS LISTED ABOVE QUALIFY, TO FUNCTION IN THE POSITION INDICATED, ACCORDING TO THE PERSONNEL REGULATIONS OF 42 CFR PART 493 SUBPART M.FORM CMS-209 (09/92) IF CONTINUATION SHEET PAGE OF 6. SIGNATURE OF LABORATORY DIRECTOR7. DATELABORATORY PERSONNEL REPORT (CLIA)(For moderate and high complexity testing)Form ApprovedOMB No. 0938-0151DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES1. LABORATORY NAME 2. CLIA IDENTIFICATION NUMBER3. LABORATORY ADDRESS (NUMBER AND STREET)CITY STATE ZIP CODE 4. Instructions:a. List below all technical personnel, by name, who are employed by the laboratory. Check () the appropriate column for each position held. For TC and TS follow instructions on reverse. For a moderate complexity laboratory, Positions:D-DirectorCC - Clinical ConsultantTC - Technical ConsultantTS - Technical Supervisor5. TELEPHONE (INCLUDE AREA CODE) FOR OFFICIAL USE ONLYlist the positions of D, CC, TC and TP. For a high complexity laboratory, list the GS - General Supervisor(NOT TO BE COMPLETED BY LABORATORY) positions of D, CC, TS, GS and TP. For cytology, list D, CC, TS, CT/GS and CT.TP- Testing Personnel INSTRUCTIONS FORM CMS-209 This form will be completed by the laboratory. It will be used by the surveyor to review the qualifications of technical personnel in the laboratory. Instructions 1.Only one person may be listed as the laboratory director (D).2.For a moderate complexity laboratory, list the positions of D, CC, TC and TP. For a high complexity laboratory,list the positions of D, CC, TS, GS and TP. For cytology, list D, CC, TS, CT/GS and CT.3.Do not list individuals that only perform waived testing, no testing, and administrative functions.4.Use a separate line for individuals performing more than one CLIA position.5.For 4(a) TC/TS:When listing those individuals holding technical consultant/technical supervisor (TC/TS) positions, use thefollowing grid to indicate the specialty(ies)/subspecialty(ies) in which they presently function. Record thenumber corresponding to the specialty/subspecialty in the appropriate column (TC/TS). When an individualfunctions as a TC/TS in more than one specialty/subspecialty, use a line for each specialty/subspecialty.GRID: 1. Bacteriology10.Clinical Cytogenetics2.Mycobacteriology 11. Histocompatibility 3.Mycology12. Radiobioassay 4.Parasitology13.Histopathology5.Virology14.Oral Pathology6.Diagnostic Immunology15.Cytology7.Chemistry16.Dermatopathology8. Hematology 17.Ophthalmic Pathology9. Immunohematology QUALIFIES ACCORDING TO SUBPART Mb. EXAMPLE Indicate highest level of testing for which personnel are qualified: Use (M) for CT/GS - Cytology General Supervisormoderate and (H) for high complexity.CT - Cytotechnologist DATE OF SURVEY a. b. EMPLOYEE NAMESPOSITION HELD M OR LAST NAME FIRST NAME MI D CC TC TS GS TP CT/GS CT H Smith John 1 M 4 H 6 H FOR OFFICIAL USE ONLY Indicate the applicable regulatory citation under which the following individuals are qualified: Each laboratory director, technical consultant, technical supervisor, clinical consultant, general supervisor, cytology supervisor, and those testing personnel and cytotechnologist sampled during the survey process. FORM CMS-209 (09/) American LegalNet, Inc. www.FormsWorkFlow.com