Free Laboratory Application for Approval to Perform Alcohol Tests-F-62501 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62501 (Rev. 07/08)

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

LABORATORY APPLICATION FOR APPROVAL TO PERFORM ALCOHOL TESTS


Completion of this form is required for a laboratory to request initial approval or approval renewal to perform blood and/or urine tests for compliance with Chapter 343.305(6)(a), Wis. Stats., relating to alcohol tests for motor vehicle drivers. Failure to provide complete information will result in a delay of permit approval. Personal information collected on this form will be used for the approval process only. Collection of the applicant's Federal Employer Identification Number 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: Supervisor, Clinical Laboratory Unit Division of Quality Assurance P.O. Box 2969 Madison, WI 53701-2969 Approval Renewal
Federal Employer Identification Number





Check one:
Name - Laboratory

Initial Approval

Address

City

State

Zip

Type Of Approval Requested URINE BLOOD

For Period Ending December 31, (Enter year.)

As director, I certify that the laboratory will comply with the requirements for approval listed below, and understand that approval may be revoked for unsatisfactory compliance with the requirements. Requirements for Approval 1. The use of a testing method(s) approved by the State Laboratory of Hygiene. 2. Only persons holding a currently valid permit, issued by the Wisconsin Department of Health Services, will perform the test. 3. Successful participation in the Wisconsin State Laboratory of Hygiene Legal Alcohol Proficiency Testing Program.
SIGNATURE ­ Director
Name - Director (Print clearly or type.) Date Signed

Degrees

Board Certification