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Laboratory Personnel Report (CLIA) CMS-209 - Official Federal Forms

Laboratory Personnel Report (CLIA) Form. This is a national form and can be used in Centers For Medicare And Medicaid Services .
 Fillable pdf Last Modified 9/13/2004
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COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESOMB NO. 0938-0151CENTERS FOR MEDICARE & MEDICAID SERVICESCalendar No.LABORATORY PERSONNEL REPORT (CLIA)(For moderate and high complexity testing)1. LABORATORY NAME2.CLIA IDENTIFICATION NUMBERJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)STATE3. LABORATORY ADDRESS (NUMBER AND STREET)ZIP CODECITY5. TELEPHONE(INCLUDE AREA CODE)4.a. List below all technical personnel, by name, who are employed by the laboratory. Check (v ) the appropriate column for each position held. For TC and TS follow instructions on reverse. b. Indicate whether shift worked is (1) day, (2) evening or (3) night. c. Indicate highest level of testing for which personnel are qualified: Use (M) for moderate and (H) for high complexity. d. Indicate whether position held is full (F) or part-time (P).Instructions:Positions:D-Director CC -Clinical Consultant TC -Technical Consultant TS -Technical Supervisor GS -General SupervisorFOR OFFICIAL USE ONLY (NOT TO BE COMPLETED BY LABORATORY) QUALIFIES ACCORDING TO SUBPART MTP-Testing Personnel CT/GS -Cytology General Supervisor CT -Cytotechnologist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DATE OF SURVEY b.c.d. M ORHF ORP EMPLOYEE NAMESCT CT/GS GS DCCLAST NAMEFIRST NAMEMITC TS TP POSITION HELD: SHIFT 123 a.THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. Address Check (v ) here if additional space is needed to list all technical personnel. Copy this page and attach continuation sheet(s) to the original form. READTHE FOLLOWING CAREFULLY BEFORE SIGNING Statement 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 or fraudulent 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.Telephone No.: Facsimile No.: E-Mail Address:6. SIGNATURE OF LABORATORY DIRECTOR:7. DATE:Mobile Tel. No.:FORM CMS-209 (9-92)IF CONTINUATION SHEET PAGE OF American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.INSTRUCTIONS FORM CMS-209Calendar No.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.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Instructions for 4(a) TC/TS: When listing those individuals holding technical consultant/technical supervisor (TC/TS) positions, use the following grid to indicate the specialty(ies)/subspecialty(ies) in which they presently function. Record the number corresponding to the specialty/subspecialty in the appropriate column (TC/TS).When an individual functions as a TC/TS in more than one specialty/subspecialty, use a line for each specialty/subspecialty.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GRID:1. Bacteriology 2. Mycobacteriology 3. Mycology 4. Parasitology 5. Virology 6. Diagnostic Immunology 7. Chemistry 8. Hematology 9. Immunohematology10. Clinical Cytogenetics 11. Histocompatibility 12. Radiobioassay 13. Histopathology 14. Oral Pathology 15. Cytology 16. Dermatopathology 17. Ophthalmic PathologyTHE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:EXAMPLEWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorableb.c.,SHIFT123 a.EMPLOYEE NAMESlocated at County ofd. M ORHF ORPLAST NAMEFIRST NAMEMIo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomCT CT/GS DCC TC TSTP POSITION HELDGS11MSmithJohnF HH4 6Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theFOR OFFICIAL USE ONLYCourt in Witness, Honorableday of, 20 County,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.(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0151.The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
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