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The American Society for Clinical Laboratory Science
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Benefits
State Society Groups
Join
Renew
Membership Packages
Education
Annual Meeting
Registration
Accommodations
Poster Abstract Submissions
CLEC
Registration
Poster Information
Accommodations
Partner Engagement
eCLECtic Blog
Webcasts-Webinars
Webinars
Educator Resources
Laboratory Educators Institute
Manager Resources
ELMC2
CE Organizer Data Transfer
Labucate Virtual Learning
Online P.A.C.E. Courses
Legislative Symposium
Communication
Social Media
Society News Now
ASCLS Today
Podcasts
ASCLS Connect Community
eNewsBytes
Clinical Laboratory Science Journal
The Bench Connection
Participate
Forums
Ascending Professionals Forum
Developing Professionals Forum
Diversity Advocacy Council
PRISM
House of Delegates
States
Committees
Governance Resources
Volunteer Opportunities
Scientific Assemblies
Lab Week-MLPW
Leadership Academy
Mentorship Program
Advocacy-Issues
Legislative Symposium
Licensure
Workforce
ASCLS Political Action Committee
Patient Safety
Labvocate Action Center
Position Papers
Careers
Career Center
Career Center – Job Search
Career Center – Employers
How do I become a laboratory professional?
Online Academic Programs
Certification Information
DCLS
DCLS Body of Knowledge
Career Recruitment Tool Kit
Laboratory Science Careers Website
P.A.C.E.
PACE Home
PACE Providers List
Online P.A.C.E. Courses
About Us
Mission Vision Statement
Code of Ethics
Board of Directors
Leadership
Leadership Directories
Leadership Resources
House of Delegates
Past Presidents
Staff
Awards and Scholarships
Education & Research Fund
History
Industry Support
ASCLS Voices Under 40
Calendar
Patient Safety Benchmark Peer Reporting Program-Registration
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Patient Safety Benchmark Peer Reporting…
General Instructions
Prior to submitting your registration, obtain approval from the appropriate facility leadership to enroll your laboratory in the program and submit your laboratory data to the Peer Comparison Program.
Only ASCLS members may submit registration request. The ASCLS member must be listed as the ‘Submitter’ on this form. ASCLS member ID number is required.
Prior to filling out this form verify that you have all registration information required.
Resource:
Patient Safety Benchmark Peer Reporting Program User Guide
.
Laboratory Name
(Required)
Laboratory Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Submitters Name
(Required)
Must be an ASCLS Member.
First
Last
ASCLS Member ID Number
(Required)
Submitter's Email
(Required)
Enter Email
Confirm Email
Contacts
Primary Contact Name
(Required)
First
Last
Primary Contact Email
(Required)
Secondary Contact Name
First
Last
Secondary Contact Email
Laboratory Certification
Laboratory Certification Status
(Required)
Choose One
CLIA Certification (CMS)
CLIA Granted Exempt Status Certification (DOD)
CLIA Granted Exempt Status Certification (Veterans Administration)
CLIA Granted Exempt Status Certification (Washington State)
CLIA Granted Exempt Status Certification (New York State)
CLIA Number
Make sure and include the "D" in the middle of your CLIA number.
CLIP Number
MTS Number
Clinical Laboratory Permit Number
CLIA Certificate Type
(Required)
Choose One
Certificate of Waiver
Certificate for Provider Performed Microscopy (PPM)
Certificate of Compliance or Certificate of Accreditation
Laboratory Demographics
Testing Complexity Levels
(Required)
Check all that apply.
Waived
PPM
Moderate
High
Testing Specialties
(Required)
Select all testing specialties that are performed within your clinical laboratory.
Chemistry (e.g., automated, and manual chemistry, urinalysis, endrocrinology, toxicology)
Hematology (e.g., automated, and manual hematology, coagulation, flow cytometry)
Microbiology (e.g., automated, and manual bacteriology, mycobacteriology, mycology, parasitology, virology, molecular diagnostics)
Immunology (e.g., automated, and manual diagnostic immunology, general immunology, molecular diagnostics)
Immunohematology (e.g., automated, and manual blood type, antibody detection and identification, compatibility testing)
Histocompatibility (transplant, nontransplant)
Genetic Testing (cytogenetic tests, biochemical genetic tests, molecular genetic tests)
Pathology (dermatopathology, histopathology, oral pathology, cytology)
Type of Laboratory
(Required)
Select the one most descriptive of facility type.
Choose One
Blood Bank
Community Clinic
Federally Qualified Health Center
Hospital
Independent Laboratory
Physician Office
Public Health Laboratory
Rural Health Clinic
School/Student Health Service
Other
Specify Other Laboratory Type
(Required)
If "Other" was chosen for laboratory type, please specify the type of laboratory.
Multiple Sites
(Required)
Does your CLIA ID/certification allow multiple testing locations under your single CLIA certificate?
Choose One
Yes
No
Multiple Location Details
Briefly list additional locations where testing is performed.
Annual Test Volume
(Required)
Refer to
‘Instructions for Counting Tests’
Choose One
<10,000 tests/year
10,001 – 100,000 tests/year
100,001 – 500,000 tests/year
>500,000 tests/year
Data precision for this program is critical. Please take the extra step and scroll up to confirm the data entered into each field is correct.
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