Clinical Microbiology CLS 2019 Clinical Microbiology Laboratory Scheme Application Form
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1 Laboratory Scheme Application Form complete all sections below and return to LGC Standards Proficiency Testing by , fax or post. Returning customer Lab ID: Purchase order no.: (compulsory) Round Despatch Date Reporting Deadline COM BTP CGC GSV GBS MRS MRM MPM SPY VRM VRE CDF VGS LG SPN AFB MTM Samples MTB MY BPS TCH HPV VIR ROT CLMI Jan 15 Feb CLMI Jan 01 Mar CLMI Jan 29 Mar CLMI Mar 12 Apr CLMI May 14 Jun CLMI May 28 Jun CLMI May 26 Jul CLMI Jul 09 Aug CLMI Jul 20 Sep CLMI Sep 11 Oct CLMI Sep 25 Oct CLMI Nov 06 Dec fill in your address details below: BCP GIP MEP RSP Send Test Materials to: Department: Company: Address: Town/City: Post/Zip Code: Country: Tel: Fax: Send Report Notifications to: # : Send Invoices to: Department: Company: Address: Town/City: Post/Zip Code: Country: Tel: Fax: VAT no: # An will be sent to this address to notify when the report is available to download from PORTAL, the online reporting system For details on the technical specification of the scheme, please refer to the CLS Scheme Description. ptcustomerservices@lgcgroup.com, Website: Page 1 of 5
2 tick the required samples in the grids below: Bacteriology Laboratory Scheme Application Form Rounds: CLMI001, CLMI004, CLMI005, CLMI008, CLMI010, CLMI012 (6 rounds per year) COM* Comprehensive Bacteriology Blood culture CSF culture Ear/Eye culture Group B Strep culture N. gonorrhoeae culture Sputum culture Stool culture Throat culture Urine colony count Urine culture Wound culture Susceptibility Testing 4 x lyophilized swab or lyophilized pellet in vial (A, B, C, and D) * note that a variation of culture types will be included in each round (with four different sample types provided each round). BTP Bordetella pertussis/parapertussis CGC C. trachomatis & N. gonorrhoeae GSV Gram Stain- Vaginitis GBS Group B Strep MRS Methicillin-Resistant Staphylococcus aureus Culture MRM Methicillin- Resistant/Methicillin-Sensitive Staphylococcus aureus MPM Mycoplasma pneumoniae SPY Streptococcus Pharyngeal VRM VRE VRE VRE Culture Bordetella pertussis; Bordetella parapertussis Chlamydia trachomatis; Neisseria gonorrhoeae Bacterial vaginosis; Nugent Score Group B Strep Methicillin-Resistant Staphylococcus aureus culture Methicillin-Resistant Staphylococcus aureus; Staphylococcus aureus Mycoplasma pneumoniae Group A Strep; Group C/G Strep Vancomycin-Resistant Enterococcus Vancomycin-Resistant Enterococcus 2 x virtual Gram stained slides (A ptcustomerservices@lgcgroup.com, Website: Page 2 of 5
3 Laboratory Scheme Application Form CDF C. difficile Toxin/Antigen VGS Gram Stain- Direct Smears LG Legionella pneumophila Antigen SPN Streptococcus pneumoniae Antigen C. difficile Toxin; C. difficile Antigen Gram Stain Interpretation; Leukocytes; Stain Quality; Sputum Specimen Quality Legionella pneumophila Antigen Streptococcus pneumoniae Antigen 3 x 1ml liquid samples (A, 2 x virtual Gram stained slides (A 2 x 0.5ml liquid samples (A 2 x 0.5ml liquid samples (A Mycobacteriology AFB Acid Fast Smears MTM Mycobacterium tuberculosis Acid Fast Bacilli Smear Mycobacterium tuberculosis complex; Rifampin resistance 3 x single-well glass slides (A, Rounds: CLMI003, CLMI007, CLMI009 (3 rounds per year) MTB Mycobacteriology Culture Mycobacteriology culture ID 3 x lyophilized loops and/ or liquid samples (A, B, and C) Mycology Rounds: CLMI002, CLMI006, CLMI011 (3 rounds per year) MY Mycology Culture Mycology culture ID Parasitology BPS Blood Parasites Blood parasite ID 3 x Giemsa stained blood smears (A, ; 2 x virtual Giemsa stained blood smears (D and E) ptcustomerservices@lgcgroup.com, Website: Page 3 of 5
4 Laboratory Scheme Application Form TCH Trichomonas vaginalis Trichomonas vaginalis 3 x 2ml liquid samples (A, Virology HPV Human papillomavirus VIR Respiratory Virology ROT Rotavirus Antigen HPV; HPV genotyping RSV Antigen; Influenza A Antigen; Influenza B Antigen; Influenza A or B Antigen; Adenovirus Antigen Rotavirus Antigen 5 x 1ml preservative solution with cells containing HPV (A, B, C, D, and E) 4 x 1ml liquid samples (A, B, C and D) 3 x 1ml liquid samples (A, Molecular Multiplex BCP Blood Pathogen Panel GIP Gastrointestinal Panel MEP Meningitis Panel RSP Respiratory Panel Identification of Yeasts Resistance Genes Identification of Parasites Identification of Yeasts Extra samples For additional samples, please state clearly your requirements below. ptcustomerservices@lgcgroup.com, Website: Page 4 of 5
5 Laboratory Scheme Application Form note: contact LGC Standards for prices. VAT is payable (at the prevailing rate) by all participants based in the UK and by those in the rest of the European Union if a VAT Registration Number is not provided. Participants outside the UK will pay an additional fee to cover courier charges. contact LGC Standards Proficiency Testing for up-to-date charges. All courier charges set by LGC Standards Proficiency Testing do not include local import charges, taxes (etc.), which will be covered by the participant. Do not send remittance with this form, you will be invoiced subsequently for the full year s participation. No refunds will be given for failure to take part in any round of the proficiency testing scheme or for cancellation of rounds that have already been invoiced. LGC Standards Proficiency Testing reserves the right to not send samples or the report for previous samples to any participant that has not paid their subscriptions within the terms stated on the invoice. LGC Standards Proficiency Testing cannot guarantee the number of participants that will return results for any particular round. The prices stated are for reporting results and receiving reports electronically via PORTAL (internet reporting). If alternative data entry or reporting methods are required, further charges apply. contact LGC Standards Proficiency Testing for the current charges. The scheme reports the performance of U.K. participants who are involved in patient care to the National Quality Assurance Advisory Panels for Chemical Pathology and for Medical Microbiology. By signing this application form, you are agreeing to comply by LGC s Standard Terms and Conditions for the Supply of Laboratory Quality Products and Services. Furthermore, for test samples containing microorganisms with a bio safety level (BSL) of 1 or 2, you are confirming that you are complying with applicable laws and regulations when using such materials. Existing customers If you would like to change your marketing preferences, please visit our preference centre or contact ptcustomerservices@lgcgroup.com New customers LGC would like to contact you by , phone or post about its products, services and related areas or research. LGC does not sell contact details to external parties. You may unsubscribe at any time. Yes, I am happy to be contacted about LGC s products, services and research No, I do not require marketing information about LGC s products and services at this time Signature Date ptcustomerservices@lgcgroup.com, Website: Page 5 of 5
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