Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

APPLICATION FOR ACCREDITATION OF DRUG TESTING LABORATORY

1
Name of Laboratory :
Address of the Laboratory :
No. & Street Barangay

City/ Municipality Province Region

Telephone/ Fax No. :
Name of Head of the
Laboratory :

Name of Owner :
Contact No. :

Classification According to
Ownership : [ ] Government [ ] Private

Character : [ ] Institution-Based [ ] Free-Standing

Service Capability : [ ] Screening [ ] Confirmatory

Status of Application : [ ] Initial [ ] Renewal

[ ] New Accreditation No.
[ ] Late Filing Date Issued
[ ] Transfer of Site Expiry Date
[ ] Change of Business Name/Ownership

Checklist of Application
Documents
Please tick ( / ) the appropriate boxes under column B or C. Items shaded are not
required.

A B C
Documents For Initial For Renewal
1. Notarized Application for Accreditation of Drug Testing Laboratory (this form)
2. Letter of Endorsement to the HFSRB Director (if filed at DOH-Regional Office)
3. List of Personnel (use attached form)
4. Photocopies of the following:
4.1. Proof of qualification of head of the laboratory, analyst and
authorized specimen collector
• PRC ID/ PRC Board Certificate, if applicable
• PSP Certificate, if applicable
• Certificate of Training/ Record of Work Experience
4.2. Proof of employment of head of the laboratory, analyst and
authorized specimen collector
5. List of Equipment/ Instrument (use attached form)
6. Duly accomplished Assessment Tool (use attached form)
7. Documentation of Chain of Custody
Form-DTL-COA-A
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The name of laboratory should match both DTI/ SEC Registration and Mayor’s/ Business Page 1 of 4
 A B C
Documents For Initial For Renewal
8. Quality Control Program (for screening laboratory) OR
Certification for Quality Standard System by a DOH recognized certifying body
(for confirmatory laboratory)
9. Certificate of Proficiency/ Proficiency Testing Result
10. Procedure Manual
11. Contract of Lease (if site is rented)
12. Health Facility Geographic Form (Location Map)
13. Photographs of the exterior and interior of the laboratory
14. Floor Layout with appropriate scale reflecting properly labeled areas to
include spatial relationship with adjacent areas if present
15. DTI/ SEC Registration (for private laboratory) OR
Issuance or Board Resolution (for government laboratory)
16. Photocopy of DOH Certificate of Accreditation

Acknowledgement

REPUBLIC OF THE PHILIPPINES )

CITY/ MUNICIPALITY OF ) S.S.

I, , , of legal age, , a resident

of
Name Civil Status Age
, after having been sworn in accordance with law hereby depose and
Address
say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the

attached documents required for the Registration and Accreditation of Drug Testing Laboratory pursuant to

R.A. 9165

“Comprehensive Dangerous Drugs Act of 2002” .

Signature

Before me, this day of 20 in the City/ Municipality of ,

Philippines, personally appeared

Owner Community Tax Number Issued at/ on

known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is

their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hands this day of 20__

Doc.No. NOTARY PUBLIC

PageNo. My Commission Expires
BookNo. Dec. 31. 20
Series of

Form-DTL-COA-A
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 List of Personnel
Annex A
Name of Laboratory :
Address of the Laboratory :

Valid
Name Designation/ Highest PRC Reg. No. Signature
Position Educational From To
Attainment

Annex A- List of Personnel

Form-DTL-COA-A
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 List of Equipment/ Instrument2
Annex B
Name of Laboratory :
Address of the Laboratory :

Brand Name & Model Serial No. Quantity Date of Purchase

Annex B- List of Equipment

Form-DTL-COA-A
Revision:01
2
Equipment/ instrument should be present, functional, and owned by laboratory applying for accreditation. 12/03/2014
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