2009 Laboratory Accreditation Readiness Toolkit
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Please complete this form, in order to receive your free toolkit. For questions related to this form, e-mail
bbadon@jointcommission.org.
Items with an asterisk (*) are required.
*
1
. First Name
First Name
*
2
. Last Name
Last Name
3
. Title
Title
4
. Organization
Organization
5
. Street Address
Street Address
6
. City
City
7
. State (Two-letter abbreviation)
State (Two-letter abbreviation)
8
. Zip Code
Zip Code
*
9
. Telephone Number
Telephone Number
10
. Fax Number
Fax Number
*
11
. E-mail Address
E-mail Address
*
12
. Which best describes your lab?
Which best describes your lab?
Hospital-based lab facility
Physician office-based lab
Independent, Reference lab
Other (please specify)
*
13
. Number of labs in your organization.
Number of labs in your organization.
1
2
3
4
5
6-10
11-15
16-20
21+
*
14
. Is your
lab
currently accredited?
Is your
lab
currently accredited?
Yes
No
15
. If so, by whom?
If so, by whom?
The Joint Commission
CAP
COLA
Other
Other (please specify)
16
. Would you like a Joint Commission representative to personally contact you?
Would you like a Joint Commission representative to personally contact you?
Yes
No
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