Form 3 Information Change Form

OMB Form No. 0920-0595

Expiration Date: XX/XX/XXXX

CDC Model Performance Evaluation Program For HIV Rapid Testing

Information Change Form

MPEP Number: «MPEPNUM»

Mailing address of laboratory: Sample Panel Shipping address for laboratory

Note: specimens cannot be mailed to PO Boxes.:

« PLNAME1» « PLADDR1» « PLADDR2» « PLCITY» « PLSTATE» « PLZIP» « PLCNTRY» Phone: «PHONE» Secondary phone: « PHONE2» Fax: «FAX» Email: «EMAIL» Secondary Email: «EMAIL2»

« SNAME1» « SNAME2» « SADDR1» « SADDR2» « SCITY» « SZIP» « SCOUNTRY» Sample Panel Shipping Contact: « SSALUTE» « S1STNAME» « SLASTNAM», « SDEGREE» Sample Panel Shipping Contact title: « STITLE»

Laboratory Director: «DIRECTOR»

Laboratory Contact: « MSALUTE » « M1STNAME » « MLASTNAM » « MDEGREE » Laboratory Contact title: « MTITLE »

In the spaces below indicate changes to be made to the current information listed above:

1. Laboratory Contact: (check one): □ Dr. □ Ms. □ Mr. □ Miss □ Mrs. □ Rev. □ Other______

Name, degree (if applicable): .

Title: .

2. Laboratory Name: .

.

Laboratory Director: .

3a. Mailing address of Laboratory (address to which correspondence should be sent):

Street / PO Box: .

.

City: . State/Province: .

Country: . Postal Code:
Telephone#: __________________ Ext: Secondary Phone#: ________________Ext:___

E-mail: Secondary email:________________________

FAX#:____________________________

3b. Shipping address to which specimens should be mailed (if different from above):

Note: specimens cannot be mailed to PO Boxes.

Street: .

.

City: . State/Province: .

Country: . Postal Code: .

4. Person completing this form:_____________________________________________________

5. Today’s Date: _______________

Scan and Email changes to the MPEP at LVaughan@cdc.gov,

Fax changes to (404) 498-2372 or mail using the enclosed pre-addressed envelope to:

If you have any questions regarding submitting your changes, you may call Leigh Vaughan, HIV-RT Project Coordinator at 404-498-2246,
or MPEP toll-free at 1-877-360-8502.

CDC MPEP Survey Coordinator

Mailstop G-23

Public reporting burden for this collection of information is estimated to average three minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, N.E., MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-0595).

1600 Clifton Rd.

Atlanta, Ga 30329-4018