Form DTL-COA-AF-2007

Republic of the Philippines

Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES

Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

Application for Accreditation of Drug Testing Laboratory

St. Luke's Medical Center Global City

Name of Laboratory1
:____________________________________________________
Address of the Laboratory :____________________________________________________
Usuan
32nd Street
No. & Street

Barangay

City/ Municipality

Province

Metro Manila
NCR
Taguig
____________________________________________________
Region

Telephone/ Fax No.

789 - 7700 Loc. 2074

:____________________________________________________

Name of Head of the

Laboratory

Dr. Ma. Cecilia F. Lim

:____________________________________________________

Name of Owner
Contact No.

St. Luke's Medical Center Global City, Inc.

:____________________________________________________
789 - 7700
:____________________________________________________

Classification According to
Ownership
: [ ] Government

[ X ] Private

Character

: [ X] Institution-Based

[ ] Free-Standing

Service Capability

: [ X] Screening

[ ] Confirmatory

: [ ] Initial
[ ] New
[ ] Late Filing
[ ] Transfer of Site
[ ] Change of Business
Name/ Ownership

[ X ] Renewal
Accreditation No. 13-0716-13-PIBS-R
____________
JANUARY 1, 2013
Date Issued ________________
Expiry Date _________________
DECEMBER 31, 2013

Status of Application

Checklist of Application Documents

Please tick (
) the appropriate boxes under column B or C. Items shaded are not required.

1.
2.
3.
4.

5.
6.
7.
1

A
Documents
Notarized Application for Accreditation of Drug Testing Laboratory (this form)
Letter of Endorsement to the BHFS Director (if filed at CHD)
List of Personnel (use attached form)
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
List of Equipment/ Instrument (use attached form)
Duly accomplished Assessment Tool (use attached form)
Documentation of Chain of Custody

B
For Initial

C
For Renewal

The name of laboratory should match both DTI/ SEC Registration and Mayors/ Business Permit.
Page 1 of 4

Form DTL-COA-AF-2007

8.

9.
10.
11.
12.
13.
14.
15.
16.

A
Documents
Quality Control Program (for screening laboratory) OR
Certification for Quality Standard System by a DOH recognized certifying body (for
confirmatory laboratory)
Certificate of Proficiency/ Proficiency Testing Result
Procedure Manual
Contract of Lease (if site is rented)
Location Map for the laboratory building
Photographs of the exterior and interior of the laboratory
Floor Layout with appropriate scale reflecting properly labeled areas to include
spatial relationship with adjacent areas if present
DTI/ SEC Registration (for private laboratory) OR
Issuance or Board Resolution (for government laboratory)
Photocopy of DOH Certificate of Accreditation

B
For Initial

C
For Renewal

Acknowledgement
REPUBLIC OF THE PHILIPPINES
)
CITY/ MUNICIPALITY OF ______________ ) S.S.

Maria Cecilia F. Lim

Single
46
______________________________,
____________, of legal age, __________,
a resident of
Civil Status
Age
Name
1801-A Aguila St., San Miguel, Manila
___________________________________________,
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
I,

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 ______________ 2007 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 _______________ 2007.

Doc. No. _____________________

Page No. _____________________
Book No. _____________________
Series of _____________________

NOTARY PUBLIC
My Commission Expires
Dec. 31. 200___

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Form DTL-COA-AF-2007

List of Personnel
Name of Laboratory
:_________________________________________________________________________________________
Address of the Laboratory :_________________________________________________________________________________________

Name

Designation/ Position

Highest Educational Attainment

PRC Reg. No.

Valid
From

To

Signature

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Form DTL-COA-AF-2007

List of Equipment/ Instrument2

Name of Laboratory
:_________________________________________________________________________________________
Address of the Laboratory :_________________________________________________________________________________________

Brand Name & Model

Serial No.

Quantity

Date of Purchase

Equipment/ instrument should be present, functional, and owned by laboratory applying for accreditation.
Page 4 of 4