Questionnaire for lab evaluation
This tool is used by CDC labs to assess the capabilities and equipment needs of labs
enrolled in the CDC Quality Control program. This form can be adapted to specific project
needs.
Lab name: __________________________________________________________________
Institution: __________________________________________________________________
Date of visit: _________________________ By: ___________________________________
Type of lab:  Government
Personnel:
 Academia
 Clinical
 Industry
 Other
Lab Director:
Other contact name:
Number of Staff:
Education and training of staff:
Analyses performed:
# of samples/Year:
Large instrumentation:
 HPLC  w/ autosampler (cooled/non-cooled)  w/ software
Type of detector:  UV/Vis  PDA  Fluor.  Electrochem.  MS  MS/MS
 GC
 CE
 ICP-MS
 AA
 MS
 NMR  IR
 UV/Vis Spectrophotometer
 Fluorometer
 Plate reader
 Plate washer
 Clinical analyzer
 SpeedVac
 Automated SPE
 Other
Peripheral equipment:
 Refrigerator
1. To be used for the storage of: lab reagents/samples/sera/chemicals/vaccines/whole
blood/other (please specify):___________________________________________
2. The operating temperature to be from ____°C to ____°C
3. Is the refrigerator temperature monitored? Yes/No
4. Capacity of _____________litres
 -20 ºC Freezer
1. To be used for the storage of: lab reagents/samples/sera/chemicals/vaccines/whole
blood/other (please specify):___________________________________________
2. The operating temperature to be from ____°C to ____°C
3. Is the freezer temperature monitored? Yes/No
4. Capacity of _____________litres

 -70 ºC Freezer
1. To be used for the storage of: lab reagents/samples/sera/chemicals/vaccines/whole
blood/other (please specify):___________________________________________
2. The operating temperature to be from ____°C to ____°C
3. Is the freezer temperature monitored? Yes/No
4. Capacity of _____________litres
Centrifuge
1. A centrifuge with speed up to ___________rpm.
2. The centrifuge should spin tubes only / tubes and bottles.
3. The size of the tubes is ______________ and bottles is _______________.
4. The rotor should be fixed angle/swing out; the large capacity rotor should have adapters for
smaller tubes.
5. There should be sealed buckets with the cap fitting into the bucket; number of buckets
required is 6 /8 / other:_________and bucket adapter size __________mL.
 Light-Protected Room
 Dry Bath
 Pipettes:
 Multi-Channel
 Repeater
 Positive Displ.
 Air Displ.
 Balance
 Sonicator
 pH Meter
 Oven/Incubator
 Waterbath
 Glassware
 Safety Glasses
 Kim wipes
 Burette
 Sharps Containers
Necessary Lab Functions
Availability of supplies needed:
 Pipette tips
 Disposable Plastic ware
 Blue Pads
 Gloves
 Biohazard Bags
 Safety goggles
Availability of chemicals:
Availability of high purity water:
Availability of constant and stable electrical power/back-up systems:
1. The local mains electricity is _______volts (V AC) ______phase
2. The local mains electricity supply is/is not subject to fluctuations in current.
3. Where these power fluctuations exist, they occur rarely/sometimes/often.
4. The local power supply is: good (no interruptions)/limited (occasional failures)/poor
(frequent interruptions).
General Lab Practices Related Evaluation
For each nutrient assessment (ex. ferritin, retinol, RBP), please fill in the following:
1. Availability of standard operating procedures (SOP’s)
2. Documentation of procedures/logbooks for maintenance and troubleshooting
3. Internal quality control
4. External quality assessment
5. Auditing/certification
Information technology related evaluation
1. Availability of computers (how many, what models)
2. Availability of computer software

Word processing
 Spreadsheet calculation

3. Availability of fax machine
4. Availability of copy machine
5. Access to the Internet
6. Access to Email
 Statistical programs
Presentations  Graphics
Problems and Comments Sheet