American Association for Laboratory Accreditation
F703 – Request for Application for Accreditation:
CLIA/ISO 15189 Testing Laboratories
Document Issued:
March 28, 2014
Page 1 of 2
Instructions: Laboratories interested in applying within the A2LA “Platinum Choice” Clinical
Accreditation Program (CLIA and ISO 15189) are asked to provide the following information. Once this
information is verified, A2LA staff will contact the individual identified below with further instruction on
the application process.
LABORATORY DIRECTOR’S NAME/TITLE: ____________________________________________
____________________________________________________________________________________
(Please attach a copy of the Laboratory Director’s medical license with this completed form.)
LABORATORY NAME (as it appears on your CLIA Certificate): ______________________________
____________________________________________________________________________________
LABORATORY ADDRESS (number and street, city, state and zip code): ________________________
____________________________________________________________________________________
TELEPHONE NUMBER: ______________________________________________________________
EMAIL ADDRESS: ___________________________________________________________________
CLIA CERTIFICATE NUMBER ASSIGNED TO THE LABORATORY: ________________________
(Please attach a copy of the certificate with this completed form.)
PLACE A CHECK MARK NEXT TO THE SPECIALTIES/SUB-SPECIALTIES FOR WHICH YOU
ARE SEEKING ACCREDITATION:
Histocompatibility
Microbiology:
Bacteriology
Mycobacteriology
Mycology
Parasitology
Virology
Diagnostic Immunology:
Syphilis Serology
General Immunology
Chemistry:
Routine Chemistry
Special Chemistry
Urinalysis
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American Association for Laboratory Accreditation
F703 – Request for Application for Accreditation:
CLIA/ISO 15189 Testing Laboratories
Endocrinology
Toxicology
Clinical Cytogenetics
Flow Cytometry
Hematology:
General Hematology
Coagulation
Immunohematology
Immunohematology
ABO Group:
Antibody Detection (transfusion)
Antibody Detection (non-transfusion)
Antibody Identification
Compatibility Testing
Rh Type
Pathology:
Histopathology
Oral Pathology
Cytology
Molecular Pathology
Radiobioassay
Document Issued:
March 28, 2014
Page 2 of 2
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ARE YOU SEEKING ACCREDITATION FOR SPECIMEN COLLECTION SITES?
____YES ____NO
ARE YOU SEEKING ACCREDITATION FOR POINT OF CARE TESTING (POCT)?
____YES ____NO
LABORATORY DIRECTOR SIGNATURE: _________________________________________
DATE: ________________________________________________________________________
Please email this completed form to Amanda McDonald, A2LA Accreditation Officer, at
amcdonald@A2LA.org.
DOCUMENT REVISION HISTORY
DATE
3/28/14
DESCRIPTION
Initial publication of document.
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