Republic of the Philippines
Department of Health
HH HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
APPLICATION FOR ACCREDITATION OF DRUG TESTING LABORATORY
Name of Laboratory1 : HEALTHPRISM MEDICAL CLINIC AND LABORATORY
Address of the Laboratory : Ph 9 Pkg 7-A Barangay Bagong Silang
No. & Street Barangay
Caloocan City, NCR
City/ Municipality Province Region
Telephone/ Fax No. : 0995 951 2646
Name of Head of the
Laboratory :
Name of Owner :
Contact No. :
Classification According to
Ownership : [ ] Government [ ] Private
Character : [ ] Institution-Based [ ] Free-Standing
Service Capability : [ ] Screening [ ] Confirmatory
Status of Application : [ ] Initial [ ] Renewal
[ ] New Accreditation No.___________
[ ] Late Filing Date Issued ________
[ ] Transfer of Site Expiry Date ________
[ ] Change of Business Name/Ownership
Checklist of Application
Documents
Please tick ( / ) the appropriate boxes under column B or C. Items shaded are not
required.
A B C
Documents For Initial For Renewal
1. Notarized Application for Accreditation of Drug Testing Laboratory (this form)
2. Letter of Endorsement to the HFSRB Director (if filed at DOH-Regional Office)
3. List of Personnel (use attached form)
4. 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
5. List of Equipment/ Instrument (use attached form)
6. Duly accomplished Assessment Tool (use attached form)
7. Documentation of Chain of Custody
Form-DTL-COA-A
Revision:01
1
The name of laboratory should match both DTI/ SEC Registration and Mayor’s/ Business Permit. 12/03/2014
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A B C
Documents For Initial For Renewal
8. Quality Control Program (for screening laboratory) OR
Certification for Quality Standard System by a DOH recognized certifying body (for
confirmatory laboratory)
9. Certificate of Proficiency/ Proficiency Testing Result
10. Procedure Manual
11. Contract of Lease (if site is rented)
12. Health Facility Geographic Form (Location Map)
13. Photographs of the exterior and interior of the laboratory
14. Floor Layout with appropriate scale reflecting properly labeled areas to include
spatial relationship with adjacent areas if present
15. DTI/ SEC Registration (for private laboratory) OR
Issuance or Board Resolution (for government laboratory)
16. Photocopy of DOH Certificate of Accreditation
Acknowledgement
REPUBLIC OF THE PHILIPPINES )
CITY/ MUNICIPALITY OF ) S.S.
I, , , of legal age, , a resident of
Name Civil Status Age
, after having been sworn in accordance with law hereby depose and
Address
say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the attached
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 20 in the City/ Municipality of ,
Philippines, personally appeared
Owner Community Tax Number 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 20__
[Link]. NOTARY PUBLIC
PageNo. My Commission Expires
BookNo. Dec. 31. 20
Series of
Form-DTL-COA-A
Revision:01
12/03/2014
Page 2 of 4
List of Personnel
Annex A
Name of Laboratory :
Address of the Laboratory :
Valid
Name Designation/ Highest Educational PRC Reg. No. Signature
Position Attainment From To
Annex A- List of Personnel
Form-DTL-COA-A
Revision:01
12/03/2014
Page 3 of 4
List of Equipment/ Instrument2
Annex B
Name of Laboratory :
Address of the Laboratory :
Brand Name & Model Serial No. Quantity Date of Purchase
Annex B- List of Equipment
Form-DTL-COA-A
Revision:01
2 12/03/2014
Equipment/ instrument should be present, functional, and owned by laboratory applying for accreditation.
Page 4 of 4