NAC Forms
Accreditation Application Form
(FR-097)
(ISO 15189 Accreditation Application Form for Medical Laboratories)
Initial accreditation
Extension of accreditation scope
The change of accreditation scope
The re-accreditation
Request accreditation and to be evaluated as a “notified medical laboratory” according related APAC documentation.
Information of the medical laboratory
Name-Identity
Address
State/City
Postal Code
Country
Telephone (incl.area code)
Fax
E-mail
Website
Tax office
Tax no
Information of head of the medical laboratory
Name and Surname
Telephone
Mobile Telephone
E-mail
Information of contact person of the medical laboratory
Name and Surname
Telephone
Mobile Telephone
E-mail
Legal status of the medical laboratory
Information of owner of the medical laboratory
Name and Surname
Address
Legal representatives of the owners
Number of medical laboratory employee
Does the medical laboratory carry out internal) calibrations?
Yes
No
Name of Carried out internal calibrations
Does the medical laboratory operate at several sites?
Yes
No
If yes, fill in the "site of medical laboratory" section below. If there are more sites, please use areas given in Annex.
Site of medical laboratory
Name-Identity
Address
City
Code
Country
Telephone
Name and Surname of Head of the site medical laboratory
Name and Surname of contact person of the site medical laboratory
Telephone of the contact person
Mobile telephone of the contact person
E-mail of the contact person
Number of the site medical laboratory employee
Does the site medical laboratory carry out internal calibrations?
Yes
No
Name of Carried out internal calibrations
Please give the examine/test scopes for which the accreditation is requested in Table-I. If medical laboratory has sites, the applications scopes must be given separately for every site
As the applicant medical laboratory, we hereby declare that the NAC Accreditation Procedures and NAC Rules are understood by us and all costs that will be invoiced consistent with NAC Service Fees Guide (K-001) will be paid by our medical laboratory. (Official Stamp)
Place
Date
Autorized Person’s Name-Surname-Signature
Reminder
FR-034 “Conformity Assessment Body Representing Person Declaration for Accreditation Services Form” and FR-001 “Accreditation Contract” (2 copies) shall be filled, signed by authorized person and attached to this application form.
After receiving the application form and annexes, your application will be uploaded to NAC Information System. Following this process, applicant testing laboratory should upload requested documents to NAC Information System.
TABLE-1 Examination /Test methods subjected to accreditation
#
(Medical Fields, Materials or products examined / tested)
(Types of examinations / Tests, Technical fields, Parameter/Analytical Methods)
(Testing Method (national, international standards, in-house methods (SOP))/ Equipment/Techniques used)
(Taking primary samples)
1
2
3
4
5
6
7
8
9
10
Site of medical laboratory (Annex A)*
Name-Identity
Address
City
Code
Country
Telephone
Name and Surname of Head of the site medical laboratory
Name and Surname of contact person of the site medical laboratory
Telephone of the contact person
Mobile telephone of the contact person
E-mail of the contact person
Number of site medical laboratory employee
Does the medical laboratory carry out internal calibrations?
Yes
No
Name of Carried out internal calibrations
Site of medical laboratory (Annex B) **
Name-Identity
Address
City
Code
Country
Telephone
Name and Surname of Head of the site medical laboratory
Name and Surname of contact person of the site medical laboratory
Telephone of the contact person
Mobile telephone of the contact person
E-mail of the contact person
Number of site medical laboratory employee
Does the medical laboratory carry out internal calibrations?
Yes
No
Name of Carried out internal calibrations
Postscript
* If there are three sites, please use area which is given at Annex-A
** If there are four sites, please use area which is given at Annex-B
