Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62503 (Rev. 07/08)

STATE OF WISCONSIN Chapter 343.305(6)(a), Wis. Stats.

APPLICATION FOR BLOOD/URINE ALCOHOL ANALYSIS PROCEDURE APPROVAL

Complete this form to obtain authorization to perform alcohol analyses per Chapter 343.305(6)(a), Wis. Stats., by the method identified below. The State Laboratory of Hygiene will approve methods for alcohol analysis. Make your information sufficiently detailed to enable another chemist to duplicate your laboratory's procedure. Unknown specimens will be provided for methodology certification and an on-going proficiency testing program. Failure to provide complete information will result in a delay of procedure approval. Collection of the applicant's Federal Employer Identification Number (FEIN) is required by Chapters 343.305(6)(e) and 73.0301, Wis. Stats. Failure to supply the number may result in denial of the application. The number will be disclosed only to the Department of Revenue for use in collection of tax delinquencies and to the Department of Workforce Development for use in administration of child and spousal support programs.



RETURN THIS APPLICATION TO:

Alcohol Program Coordinator Wisconsin State Laboratory of Hygiene Toxicology Section 2601 Agriculture Drive P.O. Box 7996 Madison, WI 53707-7996

· 1.

ATTACH A COPY OF YOUR LABORATORY PROCEDURE AS IT APPEARS IN YOUR LABORATORY PROCEDURE MANUAL.

Name - Laboratory Address Telephone Number E-mail Address City State Zip Code

Federal Employer Identification Number

Question 2 Method Codes
1 = Gas chromatography/headspace 2 = Gas chromatography/injection 3 = Alcohol dehydrogenase, automated 4 = Alcohol dehydrogenase, kit or manual 5 = Fluorometric 6 = Other

2. METHOD
(Enter code from above.)

3. ALCOHOL STANDARD(s)
Source Values Source

4. CONTROL(s)
Values

5.

Instrument, Name, Model, Etc. (Use separate page if needed.)

6.

Commercial Kit Name and Manufacturer (if used)

7.

Literature Reference(s) (must retain copy on file)

Name - Individual Completing This Form

Date