East Coast Clinical Consultants | Schedule Consultation

Select a date and time *

Select a date and time

September 2018

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Morning

Afternoon

Evening

No availability, try another day

Office *

Phone number *

Contact Name *

Title *

Email address *

Today's Date *

CAP #

CLIA #

Proficiency Acct Provider & Number

CLIA

Please select at least one option.

Does the office perform ANY lab tests in office?

Please select at least one option.

Yes

No

If yes - list tests, instrument and/or product used an attached page.

File upload

Test complexity level of office.

Does office have CLIA registration #? Expiration?

Does laboratory procedure manual include ALL tests performed?

Please select at least one option.

Yes

No

Type of HCFA inspection office signed up with:

Please select at least one option.

Fed./State

COLA

OTHER

Has office had first CLIA inspection? If yes, have report available for POC to review.

Does office have/need a N.J. State CLIS laboratory license?

OSHA

Please select at least one option.

Does the office have an OSHA Safety Manual?

Please select at least one option.

Yes

No

Does manual include: Revised Hazard, Occupational Exposure, Bloodborne, Tuberculosis and General Safety (accident, fire, electric, etc.) policies?

Please select at least one option.

Yes

No

Is personal protection and safety equipment available and used?

Please select at least one option.

Yes

No

Does office have SDS for ALL chemicals in laboratory/office?

Please select at least one option.

Yes

No

If no, a list will need to be made on day of consultation or office can make a list prior to the consultation - (laboratory only - not entire office unless OSHA services are requested)

Please select at least one option.

Has the office provided safety training in the past year?

Please select at least one option.

Yes

No

MEDICAL WASTE

Please select at least one option.

Has office been inspected by State for medical waste compliance?

Please select at least one option.

Yes

No

Are records organized in notebook?

Please select at least one option.

Yes

No

If not, office should purchase a notebook and 5 tabs and POC will help organize records.

Please select at least one option.