2016 Competency Assessment, Set A Syphilis Serology

~This exercise is a competency assessment of testing personnel for the CLIA Contract Counties. You will have one attempt to submit this report. Once you click submit at the end of the quiz, your report will be finalized. Testing personnel must evaluate two different serum samples sent to your facility by courier from NCSLPH. Please test the samples for Syphilis and enter results into the response boxes below. ~Since results will be entered using the internet, each participant must print a copy of the form to sign and keep in house. Sign and date the Attestation Statement below the test reporting area. ~All results must be submitted by the due date, February 22, 2016.
Name: 


A red asterisk (*) indicates required questions.

  1. Please enter the name of your facility. *


  1. Select the CLIA Contract Area you belong to.*
    Area A (Technical consultant-April Hill)
    Area B (Technical consultant-Tracey Shives)
    Area C (Technical consultant-Karen Wall)
    Area D (Technical consultant-Sherri Felts)
    Referee Lab


  1. Enter the date(s) of testing. *


  1. Enter the type of kit used.
    TRUST
    RPR
    ASI
    Other


  1. Enter the kit lot number.


  1. Enter the kit expiration date.


  1. 16-SS-1 Result *
    Reactive
    Non-Reactive


  1. If 16-SS-1 was REACTIVE, type in the titer result below (example, 1:1, 1:2, etc.). If titer is not performed, please leave blank and skip to Question #9.


  1. 16-SS-2 Result *
    Reactive
    Non-Reactive


  1. If 16-SS-2 was REACTIVE, type in the titer result below (example, 1:1, 1:2, etc.). If titer is not performed, please leave blank and skip to Question #11.


  1. Please rate your satisfaction with this testing format.
     
      1 2 3 4 5  
    Very Satisfied  Not Satisfied


  1. Comments?


  1. Please note that you will have ONLY one attempt to submit this report. You must print the form using your browser's print function once your quiz is complete (before submitting!). Once you have completed the quiz, sign the attestation statement and keep a copy of the quiz for your records. Attestation Statement: The results submitted on this form reflect my work only. I have not compared results with any other testing personnel. Type your name here, and sign your printed copy.*


  1. I have printed a hard copy of this quiz (using the web browser's print function.) I will not submit this quiz without having a printed copy in hand! PLEASE REMEMBER TO CLICK ON SUBMIT BELOW ONCE YOU HAVE PRINTED THE QUIZ!
    Yes
    No