Download Laboratory Logistics Date Form Completed: Name of Person

Laboratory Logistics
Date Form Completed:
Name of Person Completing Form:
Role in Laboratory:
Email:
Laboratory Director/Manager Name:
Laboratory Director/Manager Email:
Laboratory Name:
Laboratory Address:
Laboratory Telephone Number:
Clinical Research Site Affiliation (enter site name):
Clinical Research Site Address:
Is the affiliated Clinical Research Site included in the Clinical Trials Database?
 Yes  No
Clinical Trial/Network/Sponsor Affiliations (check all that apply):
 PanACEA  EDCTP  ACTG  TBTC  TB Alliance
 Pharmaceutical Company, specify:
 Other, specify:
Laboratory Capabilities
Which of the below listed tests are available at your laboratory for TB diagnosis?
Direct AFB smears?  Yes  No
If yes, check all that apply:
 Ziehl-Neelsen
 Kinyoun
 Fluorochrome
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Concentrated AFB smears?
If yes, check all that apply:
 Ziehl-Neelsen
 Yes
 No
 Kinyoun
 Fluorochrome
Solid Cultures?
 Yes  No
If yes, check all that apply:
 LJ/Ogawa
 Middlebrook agar (7H10/7H11)
Liquid Cultures?
 Yes  No
If yes, check all that apply:
 MGIT
 BacTAlert
 VersaTREK
MTB Identification?  Yes  No
If yes, check all that apply:
 PNB (p-nitrobenzoate)
 Biochemicals
 MTP64 Antigen Test
 PCR
Drug Susceptibility Testing?  Yes  No
If yes, check all that apply:
 MGIT
 Agar proportion
 MODS
 GeneXpert
 Hain LPA MTBDR plus
QUANTIFeron or T-Spot?
Other Tests?  Yes
If yes, specify:
 Yes
 Accuprobes
 LJ
 Nitrate Reduction Assay
 Hain LPA MTBDRsl
 No
 No
Are the procedures for these tests/methods standardized in accordance with the WHO/GLI Toolbox
(www.stoptb.org/wg/gli/documents.asp?xpand=3)?
 Yes  No
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Is your laboratory accredited?
 Yes  No
If yes, check all that apply:
 CAP
 ISO
 ASLM
 National program agency/organization, specify:
Does your laboratory participate in a formal external quality assessment (EQA) program (proficiency
testing)?
 Yes  No
If yes, specify which program(s):
Has your laboratory participated in registration enabling TB clinical research studies in the past 5
years?
 Yes  No
If yes, check all that apply:
 TB Diagnostic test/kit evaluations  TB Drug Trials  TB Vaccine Studies
If no, check all that apply:
 Observational
 Other, specify:
 Research
 Clinical
SUBMIT
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