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KIT EVALUATION: INFORMATION REQUEST FORM

Company:

Assay name:

Product code:

Sample volume: µl
Regulatory status:

CE Mark (European Union)
FDA (Food & Drug Administration, USA)
Other please specify

I wish to provide equipment for the evaluation:

No
Yes, please specify

I wish to train the evaluator(s) prior to commencement of the evaluation:

No
Yes
Intended application:

small scale screen
large scale screen
confirmatory
other, please specify:
Claimed sensitivity of assay: IU ng/ml pg/ml
Claimed specificity of assay: %
Please provide other information on this assay:
Date:  //
Name:  
Email:  

Thank you for your co-operation.

Please click the submit button to submit the form electronically.

Alternatively, please print the form and return to:

Dr. Keith Perry
Microbiological Diagnostics Assessment Service
Department of Evaluations and Standards Laboratory
Health Protection Agency - Centre for Infections
61 Colindale Avenue
London
NW9 5EQ

Tel: +44 (0) 208-327-6949
Fax: +44 (0) 208-327-6081
Email: midas@hpa.org.uk
Web: www.hpa-midas.org.uk

 

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