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Barangay
City/ Municipality
Province
Metro Manila
NCR
Taguig
____________________________________________________
Region
Name of Owner
Contact No.
Classification According to
Ownership
: [ ] Government
[ X ] Private
Character
: [ X] Institution-Based
[ ] Free-Standing
Service Capability
: [ X] Screening
[ ] Confirmatory
: [ ] Initial
[ ] New
[ ] Late Filing
[ ] Transfer of Site
[ ] Change of Business
Name/ Ownership
[ X ] Renewal
Accreditation No. 13-0716-13-PIBS-R
____________
JANUARY 1, 2013
Date Issued ________________
Expiry Date _________________
DECEMBER 31, 2013
Status of Application
1.
2.
3.
4.
5.
6.
7.
1
A
Documents
Notarized Application for Accreditation of Drug Testing Laboratory (this form)
Letter of Endorsement to the BHFS Director (if filed at CHD)
List of Personnel (use attached form)
Photocopies of the following:
4.1. Proof of qualification of head of the laboratory, analyst and authorized
specimen collector
PRC ID/ PRC Board Certificate, if applicable
PSP Certificate, if applicable
Certificate of Training/ Record of Work Experience
4.2. Proof of employment of head of the laboratory, analyst and authorized
specimen collector
List of Equipment/ Instrument (use attached form)
Duly accomplished Assessment Tool (use attached form)
Documentation of Chain of Custody
B
For Initial
C
For Renewal
The name of laboratory should match both DTI/ SEC Registration and Mayors/ Business Permit.
Page 1 of 4
Form DTL-COA-AF-2007
8.
9.
10.
11.
12.
13.
14.
15.
16.
A
Documents
Quality Control Program (for screening laboratory) OR
Certification for Quality Standard System by a DOH recognized certifying body (for
confirmatory laboratory)
Certificate of Proficiency/ Proficiency Testing Result
Procedure Manual
Contract of Lease (if site is rented)
Location Map for the laboratory building
Photographs of the exterior and interior of the laboratory
Floor Layout with appropriate scale reflecting properly labeled areas to include
spatial relationship with adjacent areas if present
DTI/ SEC Registration (for private laboratory) OR
Issuance or Board Resolution (for government laboratory)
Photocopy of DOH Certificate of Accreditation
B
For Initial
C
For Renewal
Acknowledgement
REPUBLIC OF THE PHILIPPINES
)
CITY/ MUNICIPALITY OF ______________ ) S.S.
documents required for the Registration and Accreditation of Drug Testing Laboratory pursuant to R.A. 9165
Comprehensive Dangerous Drugs Act of 2002.
_________________________
Signature
Before me, this _________day of ______________ 2007 in the City/ Municipality of ________________,
Philippines, personally appeared
Owner
_____________________________
Issued at/ on
_____________________________
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is
their free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2007.
NOTARY PUBLIC
My Commission Expires
Dec. 31. 200___
Page 2 of 4
Form DTL-COA-AF-2007
List of Personnel
Name of Laboratory
:_________________________________________________________________________________________
Address of the Laboratory :_________________________________________________________________________________________
Name
Designation/ Position
Valid
From
To
Signature
Page 3 of 4
Form DTL-COA-AF-2007
Serial No.
Quantity
Date of Purchase
Equipment/ instrument should be present, functional, and owned by laboratory applying for accreditation.
Page 4 of 4