Clinical Facility Fact Sheet (CLS/MT & CLT/MLT)

Institution Name:


City: State: Zipcode:

Telephone Number: Fax Number:

Accredited by (If the facility is not JCAHO, and/or CAP, and/or COLA accredited, a list of safety features is required):
Clinical Coordinator or Contact Person at site:
Clinical Laboratory Volume (specify annual number of procedures):

Indicate whether tests are performed in the following areas:

Hematology Chemistry Microbiology Immunology/Serology

Immunohematology Urinalysis Molecular Diagnostics

Total space of the laboratory:
Number of students in clinical experience assignments:
Length of time affiliation with sponsoring institution:
Length of training time:

Daytime laboratory staff (convert part-time to full-time equivalent):

  Number Employed
Credentialed Laboratorians

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