DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0544 SURVEY REPORT FORM (CLIA) SURVEYOR INSTRUCTIONS FOR CMS 1557 225For specialty(ies)/subspecialty(ies) added or deleted: Use the space provided to list corresponding information and effective dates.225For : Any comments pertinent to the survey or determination of compliance can be listed here.225Each surveyor must on page 2 for each type of survey conducted (see 223survey status;224 223other224 may includefollow-up visit to verify a POC).GENERAL INFORMATION CLIA IDENTIFICATION NUMBER DATE OF SURVEY LABORATORY NAME TELEPHONE NUMBER (include area code) LABORATORY ADDRESS (number, street) CITY STATE ZIP MAILING ADDRESS (if different from above) CITY STATE ZIP NAME OF DIRECTOR SURVEY STATUS: (Check all that apply) STATE/COUNTY CODE STATE REGION CODE State Exemption (State) Accreditation (Organization) ValidationAddition of (Sub)Specialty(ies) ComplaintOther (Specify) STATE LICENSE NUMBER (if applicable) MEDICARE PROVIDER NUMBER(S) PERSONNEL: SHOW NUMBER OF PEOPLE QUALIFIED UNDER EACH APPLICABLE REGULATORY SECTION DIRECTOR CLINICAL CONSULTANT TECHNICAL CONSULTANT MODERATE COMPLEXITY MODERATE COMPLEXITY MODERATE COMPLEXITY 493.1417 (b)(1)(6) (a) (b)(1)( )(2)(7)(b) (2) ( )(3)( )( ) (3) (4)( )( ) (4) (5)( )DIRECTOR CLINICAL CONSULTANT TECHNICAL SUPERVISOR GENERAL SUPERVISOR HIGH COMPLEXITY HIGH COMPLEXITY HIGH COMPLEXITY 493.1449(a) HIGH COMPLEXITY 493.1461(a) 493.1455 (b)(1)( ) (b)(h)(n) (b)(1) (d)(1) (2)( )(a) (c)(i)(o) (b)(2) (d)(2) (3)(4)(5)(b) ( ) ( ) (d)(j)(p) (e)(*)(q) (f)(l)( ) (g)(m)( ) (c)(1) (d)(3) (c)(2) (e) (c)(3) ( ) CYTOTECHNOLOGIST TECHNICAL SUPERVISOR GENERAL SUPERVISOR CYTOLOGY 493.1469 (b)(1)(4) (2)(5)(k)(1)( )(a)( )(3)( )(2) ( )(b)( ) According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0544. Expiration Date: //. The time required to complete this information collection is estimated to average 30 min-utes per response, including the time to review instructions, search existing data resources, gather the data needed, and completeand review the information col-lection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, pleasePlease do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRAnumber listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, pleasecontact LabExcellence@cms.hhs.gov. PAGE 1 FORM CMS-155) American LegalNet, Inc. www.FormsWorkFlow.com 001001001001001001001001001001001001001001001001 001001001001001001001001001001001001001001001001001001001001001 SPECIALTIES/SUBSPECIALTIES ACCREDITED PROGRAM ANNUAL TEST VOLUMES (SUB)SPECIALTY(IES) ADDED EFFECTIVE DATE (SUB)SPECIALTY(IES) DELETED EFFECTIVE DATE PROFICIENCY TESTING 010 001 Histocompatibility NA A 001 Transplant B 001 Nontransplant 100 001 Microbiology 110 001 Bacteriology 115 001 Mycobacteriology 120 001 Mycology 130 001 Parasitology 140 001 Virology 150 001 Other 200 001 Diagnostic Immunology 210 001 Syphilis Serology 220 001 General Immunology 300 001 Chemistry 310 001 Routine 320 001 Urinalysis 330 001 Endocrinology 340 001 Toxicology 350 001 Other 400 001 Hemtology 500 001 Immunohematology 510 001 ABO Group & Rh Type 520 001 Antibody Detection (transfusion) 530 001 Antibody Detection (nontransfusion) 540 001 Antibody Identification 550 001 Compatibility Testing 560 001 Other 600 001 Pathology 610 001 Histopathology NA 620 001 Oral athology NA 630 001 Cytology 800 001 Radiobioassay NA 900 001 Clinical Cytogenetics NA Are immunohematology tests performed for transfusion purposes? ......................................................................................... 001 Yes 001 No Are blood and/or blood products (including autologous) collected? .......................................................................................... 001 Yes 001 No For a partial survey (validation, addition of (sub)specialty, complaint, or follow-up) list the laboratory condition(s) regulation number(s) reviewed: In accordance with current survey procedures, this laboratory was found to be in compliance with program requirements. SIGNATURE DATE SIGNATURE DATE SIGNATURE DATE FORM CMS-1557 PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com SURVEY WORKSHEET (CLIA) PAGE OF NAME OF SURVEYOR NAME OF FACILITY DATE OF SURVEY (MMDDYY) CLIA IDENTIFICATION NUMBER FORM CMS-1557 PAGE 3 American LegalNet, Inc. www.FormsWorkFlow.com 002 SURVEY WORKSHEET (CLIA) (CONTINUED)037 FORM CMS-1557 PAGE 4 American LegalNet, Inc. www.FormsWorkFlow.com