NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME (NEQAS)

FOR BACTERIOLOGY, PARASITOLOGY & MYCOBACTERIOLOGY

NEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASSSSSSNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASN EQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQAS

Department of Health
Research Institute for Tropical Medicine
LABORATORY ENROLLMENT FORM
Lab ID No: 3 0 8 3
(NEQAS USE)
PLEASE WRITE LEGIBLY IN BLOCK AND ALL CAPITAL LETTERS. DO NOT LEAVE ANY SPACES BLANK.IF NOT APPLICABLE, WRITE N/A
1. Name of laboratory/hospital (No abbreviations please):
MEDINA HOSPITAL
2. Address:
*KINDLY SUBMIT THE ORIGINAL COPY DURING REGISTRATION

TANGAN-RAGOT STREET NORTH POBLACION MEDINA MISAMIS ORIENTAL 9013

No, Street Barangay Municipality/City Province Postal Code
3. Tel: 0965-4083-704 4. Fax: N/A 5. Web/E-mail: mh-npm@yahoo.com

6. Contact Person: 7. Contact Person Tel/mobile No: 8. Contact Person E-mail:

BERNADETTE C.CABANA CULLEN JAY M.LAPLANA N/A
9. Please answer the following:
 Have your hospital/laboratory ever participated in NEQAS? / Yes No (Please proceed to no. 10)
Year last participated: Hosp/Lab ID no.
 If “Yes”, indicate last year of participation and fill-in your
NEQAS assigned hospital/laboratory ID number. 2 0 1 9 3 0 8 3
10. Hospital/Laboratory ownership: 11. Laboratory Category
/ Government Private Semi-private Primary / Secondary Tertiary Special
12. Hospital chief/director: 13. Laboratory chief/head:
DR.RAMON F.MORENO, MD,FPCP DR. JERRY C. ABROGUEÑA,MD,FPSP
14. Head of Bacteriology: 15. Head of Parasitology:
N/A N/A
16. Head of TB Laboratory: 17. Please indicate the best way to contact you:
N/A N/A
18. Will you pick up the test samples from a nearby courier? (If YES, please indicate the LBC branch: i.e. LBC Tabuk Branch)
/ No. Couriers are able to deliver directly to our location. Yes. We will pick up the test samples from _____________________________
Please check which program your laboratory would like to enroll:
Bacteriology / Parasitology TB Microscopy TB Culture (optional)
Requirements:
1. Enrollment Form (download at http://ritm.gov.ph/forms/)
2. Payment (see Method of Payment)
3. Photocopy of the latest Certificate of Participation to any Department of Health recognized Bacteriology, Parasitology or TB
External Quality Assessment (EQA) provider if not enrolling in any one of the three programs except TB Culture
Method of Payment*:
Cheque (Manager’s/Cashier’s cheque ONLY --payable to RESEARCH INSTITUTE FOR TROPICAL MEDICINE)
*PLEASE DO NOT USE ANY OTHER FORM EXCEPT THIS ONE.

/ Postal Money Order (P.M.O. payable to RESEARCH INSTITUTE FOR TROPICAL MEDICINE)
Cash (Only for walk-in applicants. Direct bank deposits are NOT ALLOWED)
LANDBANK Electronic Payment Portal (online payment using ATM/Debit Cards | https://epaymentportal.landbank.com)**
*Please proceed or contact the NEQAS office for clarifications **Complete instructions are listed at the back
Enrollment Procedure:
1. Enrollment is only from April to May of the year cycle. LATE Programs Amount
ENROLLEES WILL NOT BE ACCEPTED OR INCLUDED IN THE PROFICIENCY Bacteriology, Parasitology, TB P 7,500.00
TEST EVENT. Bacteriology with/without Parasitology or TB P 7,500.00
2. Fill out the Enrollment Form correctly and sign Parasitology and TB P 4,200.00
3. Refer to the box on the right for the amount to be paid or contact the Parasitology or TB P 4,200.00
NEQAS office for clarification
4. Send Enrollment Form and Payment (or proof of payment for online payment option) to the NEQAS Office for payment evaluation and
processing. LABORATORIES THAT WILL NOT COMPLY ON THE REQUIREMENTS STATED ABOVE AND PAYMENTS WITH INCORRECT AMOUNT WILL
NOT BE ACCEPTED.
NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME
Department of Microbiology
Research Institute for Tropical Medicine
FILINVEST, Alabang, Muntinlupa City
5. Official Receipts will be sent together with the Proficiency Test samples for laboratories that will send their payments online or via courier.

I certify that I have read and understood the procedures for enrollment and certify Bank & Cheque No.

NEQAS USE
that the above information is true and correct.

BERNADETTE C.CABANA,RMT
________________________________________ OR No.
Print name and Signature

National External Quality Assessment Scheme V 7.0 (21-Nov-17)

Research Institute for Tropical Medicine
Filinvest, Alabang, Muntinlupa City, Metro Manila
Direct Line: (02) 850-1949 | Email: mcb.neqas.ritm@gmail.com
 NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME (NEQAS)
FOR BACTERIOLOGY, PARASITOLOGY & MYCOBACTERIOLOGY
NEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASSSSSSNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASN EQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQASNEQAS

Department of Health
Research Institute for Tropical Medicine
LANDBANK Electronic Payment Portal* steps:
1. Go to http://epaymentportal.landbank.com
2. Click Pay Bills.
3. Select Research Institute for Tropical Medicine (RITM) under R.
4. Select Registration Fee: NEQAS PT-MICRO.
5. Fill-out Transaction Form. Enter code for CAPTCHA.
*KINDLY SUBMIT THE ORIGINAL COPY DURING REGISTRATION

6. Review Transaction Details. If all information are correct, click “Submit”.

7. Choose Payment Option (e.g. LANDBANK ATM card).
8. Tick box for Terms and Conditions. Click “Submit”.
9. At the end of the Payment Details Page, input the following information:
a. 10-digit Account Number
b. Joint Account Indicator (JAI), and
c. Personal Identification Number (PIN)
10. Click “Submit”, then “Print Debit Confirmation”.
11. Click “Close Window” to begin another transaction.

Eligible Client Accounts:

1. LANDBANK ATM Cards
2. LANDBANK Visa Debit Cards
3. BancNet member banks’ ATM/Debit Cards

A minimum transaction fee of P20.00 will be charged per successful transaction (additional P10.00 will be charged
when using other BancNet member banks’ ATM/Debit Cards) and a payment confirmation receip t will be provided
for your reference.

*If you choose to pay via LANDBANK Electronic Payment Portal, do not forget to send the filled up enrollment
form together with the payment confirmation receipt to NEQAS office for Registration. Incomplete
documents will not be processed.
*PLEASE DO NOT USE ANY OTHER FORM EXCEPT THIS ONE.

National External Quality Assessment Scheme V 7.0 (21-Nov-17)

Research Institute for Tropical Medicine
Filinvest, Alabang, Muntinlupa City, Metro Manila
Direct Line: (02) 850-1949 | Email: mcb.neqas.ritm@gmail.com