National Reference Laboratory for HIV/AIDS, Hepatitis and other STIs
STD/AIDS COOPERATIVE CENTRAL LABORATORY
Bldg. 17, San Lazaro Compound, Quiricada St., Sta. Cruz, Manila Tel: 309-9528 / 309-9529 Fax No: 711-4117 Email: saccl@[Link] website [Link]/saccl
Training Application Form-2 Renewal of Proficiency Certificate Applicants profile
Surname Age/Sex Home Address: First Name Date of Birth PRC License/ Expiry Date Tel. No. Cell no: Email: Trainer: SACCL Date RITM BRL Place MI Religion
HIV Proficiency Certificate Date Issued: No.: Trainings attended related to HIV or STIs for the last 5 years
(use separate sheet if necessary)
Total months rotated in HIV serology
Number of tests performed/ month
Number of HIV testing lab s handled (use separate page for the
profile of each labs)
Schedule of duties in each HIV serology lab. A: B: Participation in HIV External Quality Assurance Program: Yes No Score: _______________ Position
Method of tests used in HIV testing: Rapid PA EIA Others: _________________ Employment record Name of employer A: B: Brief present job description:
Equipment used: Pipettor EIA washer EIA reader none
Other serological tests performed: HAV HBV HCV Syphilis Date of service
Permanent Permanent
Part-time Part-time
I accept that after the training, I agree: 1. to carry out such instructions and abide by the conditions as maybe stipulated by both the nominating agency and by the training institution; 2. to follow the course of the training and abide the rules of the training institution which I undertake to train; 3. to transfer the technology learned to my colleague and to remain in my agency for a period that I and my nominating agency have agreed upon; 4. to return to my ________________________(agency) as soon as training ceases. Date filed: ____________________ _____________________________________________
PRINTED NAME AND SIGNATURE OF PARTICIPANT
Page 2 of HIV renewal of cert. application
Laboratorys Profile
(for the applicant who handles more than one HIV facilities must use and submit laboratorys profile separately)
Name of agency & address:
Tel. no.: Fax no: Email: Designation:
Name of the head of the agency:
Ownership Institutional Character Service Capability Government Private Institution based Free-standing Primary Secondary Tertiary License to operate? HIV Accredited? Purpose of HIV testing? Yes No Yes No Diagnosis Blood transfusion both Give a brief description of works and services of your laboratory department it provide:
Name
List of HIV Proficient MT in the laboratory: HIV Prof. Cert. no /Date issued
Trainer
(Ex: BRL, RITM, SACCL)
HIV testing laboratory capability: Please, check if any of the ff: Name of Reagents used HIV-Ab testing PA Others Rapid EIA Syphilis testing RPR Others TPPA/TPHA Hepatitis B testing Rapid Others EIA Hepatitis C testing Rapid Others EIA Enumerate any agencies you cater in your laboratory:
Ave. Number of specimens done/month
I certify that the above information written thereto is true and correct with the best of my ability. This certification is hereby granted upon the request of Mr/Ms_______________________ for whatever purpose it may serve.
(name of proficient med. tech.)
____________________________________________
NAME AND SIGNATURE OF THE HEAD OF THE AGENCY Date:
NRL- SACCL/SLH ASSESSMENT: Category I Reviewed by: ____________________________________ Category II Category III Date: ______________________________
Recommendation:_______________________________________________________________________ __________________________________________________________________________ 2
REQUIREMENTS FOR RENEWAL OF HIV PROFICIENCY CERTIFICATE 1. Accomplished application form for the renewal of HIV proficiency certificate provided by the NRLSACCl/SLH ( a prototype of the application forms are posted at the DOH website [Link]/saccl ) and must be signed by the pathologist of the sending agency; b. Photocopy of previous HIV proficiency certificate; c. Quarterly census form for HIV and other blood-borne infections; d. Certificate of performance signed by pathologist or chief medical technologist; e. Certificate of training, seminar or convention (related to HIV and other blood-borne infection); 2. 2 copies of 2x2 colored ID picture with white background; 3. Renewal fee (depending on the category of the applicant) to be paid at the San Lazaro Hospital.
CATEGORIES OF PROFICIENT MEDICAL TECHNOLOGIST REQUIRING RENEWAL OF CERTIFICATE 1. Category I Medical technologists performing HIV test with proficiency certificate acquired after year CY 2001 shall undergo training seminar update. 2. Category II Medical technologists performing HIV test with proficiency certificate acquired before CY 2000 shall undergo refresher course. 3. Category III Non-performing HIV proficient medical technologist and those with expired proficiency certificates shall undergo initial HIV proficiency training for reinstatement.
Submit all the requirements by mail at: National Reference Laboratory for HIV/AIDS, Hepatitis and other STIs STD/AIDS COOPERATIVE CENTRAL LABORATORY Bldg. 17, San Lazaro Compound, Quiricada St., Sta. Cruz, Manila 1003 For inquiry, please contact training coordinator at the following numbers: Tel: 309-9528 / 309-9529 Fax No: 711-4117 Or send your queries at: Email: saccl@[Link] website [Link]/saccl
Training schedules will be informed to participant by sending acceptance letter thru fax or mail.
