DAP Proficiency Testing Enrollment Form 2012

Facility:
Specialty/Subspecialty / PT
Provider / Specialty/Subspecialty / PT
Provider / Specialty/Subspecialty / PT
Provider
Chemistry / Chemistry cont. / Chemistry cont.
5-HIAA / CO2, total / Lipoprotein (a)
17-Hydroxyprogesterone / Copper / Lithium
25-OH Vitamin D / Cortisol / Luteinizing hormone (LH)
Acetaminophen / C-reactive protein (CRP) / Magnesium
Albumin / Creatine kinase (CK) / Metanephrines
Aldosterone / Creatinine / Microalbumin
Alkaline phosphatase / Cyclosporin / Mycophenolic acid (MPA)
ALT / DHEA / DHEA sulfate / Osmolality
Amylase / Digoxin / Phenobarbital
Androstenedione / Erythropoietin / Phenytoin
Anti-TPO antibody / Estradiol / Phosphorus
Apolipoprotein A1 / Ethosuximide / Potassium
Apolipoprotein B / Ferritin / Primidone
AST / Fetal fibronectin (fFN) / Procainamide
Bilirubin, total / Folate / Prolactin
Blood Gases – pCO2 / Follicle-stimulating hormone (FSH) / Propoxyphene
Blood Gases - pH / Gamma-glutamyl transferase (GGT) / Protein electrophoresis
Blood Gases – pO2 / Gentamicin / Protein, total
BNP / NT-proBNP / Glucose / PTH
Calcium, ionized / Growth hormone (GH) / Quinidine
Calcium, total / Haptoglobin / Renin
Carbamazepine / Hemoglobin A1C / Salicylate
Catecholamines / Human chorionic gonadotropin (hCG) / Sirolimus
*Celiac serology / IGF-1 (somatomedin C) / Sodium
Chloride / Insulin / T3, free
Cholesterol, HDL / Iron, total / T4, free
Cholesterol, LDL / Lactate dehydrogenase (LD) / Tacrolimus
Cholesterol, total / Lead, blood / Testosterone
CK-MB / Lipase / Theophylline
Chemistry cont. / Hematology / Serology/Immunology
Thyroid-stimulating hormone (TSH) / Auto/Manual WBC differential / Alpha 1-antitrypsin
Tobramycin / Erythrocyte count / Leukocyte count / Alpha-fetoprotein (AFP)
Total Iron-binding capacity (TIBC) / Hematocrit (automated) / Anti-streptolysin O, (ASO) quantitative
Transferrin / Hemoglobin / * Autoimmune profile
Triglycerides / Platelet count / Complement C3
Troponin I / Troponin T / Reticulocyte count (automated) / Complement C4
* Tumor markers / Cell identification/morphology / lgA
Unsaturated Iron-binding capacity (UIBC) / Body fluid cell count / lgE
Urea / * Hemoglobinopathy testing / IgE – allergen specific
Uric acid / Coagulation / lgG
* Urine drugs of abuse / INR / IgM
Valproic Acid / Activated partial thromboplastin time (APPT) / Rheumatoid factor
Vancomycin / Fibrinogen / Transfusion Medicine
Vitamin B12 / D-dimer / ABO grouping
Vanillylmandelic acid (VMA) / Anti-Thrombin / Antibody identification
Zinc / dRVVT / Compatibility testing
Microbiology / Factor assays / DAT
Bacteriology / Protein C / Rh (D) typing
Mycobacteriology / Protein S / Unexpected antibody detection
Mycology / Anatomic Pathology / Cytogenetics
Parasitology / All Class II Immunohistochemistry (IHC) testing / Cytogenetics proficiency testing enrollment is required for all types of services offered
Virology
Serology
Microbiology proficiency testing enrollment is required for all types of service offered in each of the above subspecialties. / * Categories indicated by asterisk include all types of service that are offered in that category.

DAP Approved Proficiency Testing Providers 2012:

* Enter the number corresponding to the PT provider in the forms above (e.g. enter 9 if using CAP)

Diagnostic Accreditation Program

Suite 501 – 777 West Broadway, Vancouver, BCV5Z 4J7

Page 1 of 4

  1. Alberta Laboratory Quality Enhancement Program (ALQEP)
  2. American Association of Bioanalysts (AAB)
  3. American Proficiency Institute (API)
  4. Bio-Rad Laboratories (EQAS)
  5. British Columbia Immunohistochemistry Proficiency Testing Program (BC-IPT)
  6. Canadian Immunohistochemistry Quality Control (cIQc)
  7. Centers for Disease Control and Prevention (CDC)
  8. Centre de Toxicologie du Quebec
  9. College of American Pathologists (CAP)
  10. Clinical Microbiology Proficiency Testing (CMPT)
  11. HealthMetrx (DigitalPT)
  12. Nordic Immunohistochemistry Quality Control (NordiQC)
  13. Quality Management Program – Laboratory Services (QMPLS)
  14. Randox Laboratories(RIQAS)
  15. UK National External Quality Assessment Service (UK NEQAS)
  16. Vitamin D External Quality Assessment Scheme (DEQAS)
  17. Wisconsin State Laboratory of Hygiene (WSLH)

Diagnostic Accreditation Program

Suite 501 – 777 West Broadway, Vancouver, BCV5Z 4J7

Page 1 of 4

Attestation Form for Proficiency Testing

Name of Organization
Address
Primary Contact and Title
Telephone Number
Email Address
Name of Site Laboratory Director
Site Laboratory Medical Director must sign below

I hereby attest that:

  1. Each laboratory, as appropriate, is enrolled with a DAP approved Proficiency Testing provider and participates in a Proficiency Testing program that meets the mandates of the DAP with respect to the variety of testing for the period:

January 1, 2012 to December 31, 2012.

  1. All non-mandated analytes which are not enrolled in a formal PT program will have the accuracy of their test results verified at a minimum of twice a year as outlined in the September 21, 2011 letter: “DAP Processes for Proficiency Testing 2012"
  1. Recognizing that some special handling may be required due to the nature of PT materials, all surveys will be performed as closely as is practical to patient specimen analysis.

Signature of Site Laboratory Medical DirectorDate

Diagnostic Accreditation Program

Suite 501 – 777 West Broadway, Vancouver, BCV5Z 4J7

Page 1 of 4