Kansas HIV Counseling and Testing Rapid

CLIA Incident Report

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Kansas HIV Counseling and Testing Rapid CLIA Incident Report

All Test requests are completed in the order in which they are received. Please allow up to a week for processing.

* Denotes required fields.

* Date and Time Reported:

* Facility Name:

* Facility ID #:

* Name of person reporting:

* Phone Number:
* Email:

Please indicate below the reason for submitting the Kansas HIV Counseling and Testing Rapid CLIA Incident Report:

Defective Test Kit
Faulty/Malfunctioning Test Kit
Operator Malfunction
Invalid Rapid HIV Test Kit
Invalid or Defective Controls

If the Rapid HIV kit was invalid, faulty or defective was the client retested?

Yes No

If YES, please indicate the HIV Test Form ID and Client ID used to re-test.
Client ID #:

Test Form ID #:

* Please describe the circumstances regarding the incident:

Please enter description here.

If follow-up activities are required, please describe below:

Please enter description here.

PLEASE RETAIN A COPY OF THIS SUBMISSON FOR YOUR RECORDS

Questions: Contact Jamie Flemming at (785) 296-6545 or Fax: (785) 296-4197.

Kansas HIV Counseling and Testing RapidCLIA Incident Report

Kansas HIV Counseling and Testing Rapid CLIA Incident Report

Kansas HIV Counseling and Testing Rapid

CLIA Incident Report