Observe blood and urine collection procedures on at least one applicant

*1.Name of Contractor Completing Survey:(Required.)

2.Are blood and urine collected onsite?

Yes

No

If no, where are blood and urine samples collected?

*3.Barcodes or unique lab IDs used instead of names.(Required.)

True

False

*4.Proper PPE used during specimen collection procedures.(Required.)

True

False

*5.Hand hygiene is conducted before and after applicant care.(Required.)

True

False

*6.Samples are stored appropriately and, if needed, transported appropriately.(Required.)

True

False

*7.Sharps are disposed of in a WHO approved sharps container.(Required.)

True

False

*8.Applicants are accompanied to restrooms used or urine collection.(Required.)

True

False

*9.Applicant’s belongings and family are prohibited in the restrooms used for urine collection.(Required.)

True

False

*10.Urine sample is confirmed to be urine (e.g., temperature is monitored, toilet water is dyed blue, etc.)(Required.)

True

False

*11.List the average turnaround times for the following tests:(Required.)

Syphilis screening test

Syphilis confirmation test

Gonorrhea test

IGRA

*12.Additional comments on specimen collection procedures (open comment):(Required.)