A1: On-Site Evaluation Comprehensive Checklist

**Laboratory:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**District *or* Administrative Unit:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Laboratory Supervisor/Head of Laboratory:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Date of Visit:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Number of Microscopists/Technicians:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Current Laboratory Staff Qualifications:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SECTIONS 1-9, and 14 MAY BE FILLED OUT BY LABORATORY OR NON-LABORATORY
STAFF SUPERVISING THE CLINIC OPERATIONS. SECTIONS 10-13 ARE DETAILED
LABORATORY EVALUATIONS THAT SHOULD ONLY BE COMPLETED BY TRAINED
LABORATORY STAFF.**

**1. Standard Operating Procedures**

> Are written standard operating procedures for laboratory methods and
> equipment *(e.g. NTP laboratory manual)* available and accessible? Y N
>
> If no, explain:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2. Laboratory Reagents**

+---------------------------------+-----------+-----+--------+-------+
| **Observe and Question**        | **In      |     |        |       |
|                                 | dicator** |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
| Are all staining reagents       | Reagent   | Ava | Within | Ade   |
| available?                      |           | ila | expi   | quate |
|                                 |           | ble | ration | Sup   |
| Have there been any shortages   |           |     | date   | ply\* |
| of reagents within the last     |           |     |        |       |
| three months? (\*Adequate       |           |     |        |       |
| supply is defined as available  |           |     |        |       |
| current supply and no shortages |           |     |        |       |
| over the past three months.)    |           |     |        |       |
|                                 |           |     |        |       |
| Observe that all reagents in    |           |     |        |       |
| use are within expiration date  |           |     |        |       |
|                                 |           |     |        |       |
| Observe that Immersion Oil has  |           |     |        |       |
| acceptable viscosity (not too   |           |     |        |       |
| thick or too thin) (Will        |           |     |        |       |
| require training of non-lab     |           |     |        |       |
| supervisor)                     |           |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Carbol    | Y N | Y N    | Y N   |
|                                 | Fuchsin   |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Methylene | Y N | Y N    | Y N   |
|                                 | Blue      |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Sulphuric | Y N | Y N    | Y N   |
|                                 | Acid 25%  |     |        |       |
|                                 |           |     |        |       |
|                                 | Or        |     |        |       |
|                                 |           |     |        |       |
|                                 | Acid      |     |        |       |
|                                 | Alcohol   |     |        |       |
|                                 | 3%        |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Immersion | Y N | Y N    | Y N   |
|                                 | Oil       |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Xylene    | Y N | Y N    | Y N   |
+---------------------------------+-----------+-----+--------+-------+

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Action Required
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3. Laboratory Supplies**

+---------------------------------+-----------+-----+--------+-------+
| **Observe and Question**        | **In      |     |        |       |
|                                 | dicator** |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Material  | Ava | Good   | Ade   |
|                                 |           | ila | Con    | quate |
|                                 |           | ble | dition | S     |
|                                 |           |     |        | upply |
|                                 |           |     |        | \*    |
+---------------------------------+-----------+-----+--------+-------+
| Are the following items         | Slides    | Y N |        | Y N   |
| available?                      |           |     |        |       |
|                                 | Frosted   |     |        |       |
| Is the type of sputum           | Slides    |     |        |       |
| containers in use approved by   |           |     |        |       |
| the NTP?                        |           |     |        |       |
|                                 |           |     |        |       |
| Check to determine that slide   |           |     |        |       |
| boxes are adequate design       |           |     |        |       |
| (slides are stored standing up  |           |     |        |       |
| to drain oil and without        |           |     |        |       |
| touching each other) and number |           |     |        |       |
| (sufficient boxes to store the  |           |     |        |       |
| number of slides required for   |           |     |        |       |
| adequate sampling)              |           |     |        |       |
|                                 |           |     |        |       |
| Have there been any shortages   |           |     |        |       |
| of supplies within the past     |           |     |        |       |
| three months? (\*Adequate       |           |     |        |       |
| supply is defined as available  |           |     |        |       |
| current supply and no shortages |           |     |        |       |
| over the past three months.)    |           |     |        |       |
|                                 |           |     |        |       |
| A clean water supply should be  |           |     |        |       |
| available distilled water is    |           |     |        |       |
| recommended. Water should be    |           |     |        |       |
| stored in bottles free of       |           |     |        |       |
| environmental contaminants      |           |     |        |       |
| including bacteria and fungus.  |           |     |        |       |
| Water from stagnant containers  |           |     |        |       |
| should not be used.             |           |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Slide     | Y N | Y N    | Y N   |
|                                 | Boxes     |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Sputum    | Y N |        | Y N   |
|                                 | C         |     |        |       |
|                                 | ontainers |     |        |       |
|                                 | approved  |     |        |       |
|                                 | by NTP    |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Diamond   | Y N | Y N    | Y N   |
|                                 | Pencil    |     |        |       |
|                                 | (or)      | Y N |        |       |
|                                 |           |     |        |       |
|                                 | Pencils   |     |        |       |
|                                 | (use with |     |        |       |
|                                 | frosted   |     |        |       |
|                                 | slides)   |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Wire      | Y N | Y N    | Y N   |
|                                 | Loops     |     |        |       |
|                                 |           | Y N |        | Y N   |
|                                 | or        |     |        |       |
|                                 |           |     |        |       |
|                                 | Sticks    |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Funnel    | Y N | Y N    |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Filter    | Y N |        | Y N   |
|                                 | Paper     |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Staining  | Y N | Y N    | Y N   |
|                                 | Racks     |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Spirit    | Y N | Y N    |       |
|                                 | Lamp      |     |        |       |
|                                 |           |     |        |       |
|                                 | Or Bunsen |     |        |       |
|                                 | Burner    |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Fuel for  | Y N |        | Y N   |
|                                 | spirit    |     |        |       |
|                                 | lamp      |     |        |       |
|                                 |           |     |        |       |
|                                 | Or Gas    |     |        |       |
|                                 | for       |     |        |       |
|                                 | burner    |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Lens      | Y N |        | Y N   |
|                                 | Tissue    |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Red Pen   | Y N |        |       |
|                                 | for       |     |        |       |
|                                 | recording |     |        |       |
|                                 | Positive  |     |        |       |
|                                 | Results   |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Water     | Y N | Y N    | Y N   |
|                                 | supply    |     |        |       |
+---------------------------------+-----------+-----+--------+-------+
|                                 | Balance   | Y N | Y N    |       |
|                                 | (for      |     |        |       |
|                                 | weighing  |     |        |       |
|                                 | reagents) |     |        |       |
+---------------------------------+-----------+-----+--------+-------+

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Action Required
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**4. Laboratory Safety**

+---------------------------------+-----------------------------+-----+
| **Observe and Question**        | **Indicator**               |     |
+---------------------------------+-----------------------------+-----+
| Where is TB work performed?     | TB work is performed in an  | Y N |
|                                 | area separate from other    |     |
|                                 | laboratory procedures       |     |
+---------------------------------+-----------------------------+-----+
|                                 | There are separate tables   | Y N |
|                                 | for smear preparation and   |     |
|                                 | microscopy                  |     |
+---------------------------------+-----------------------------+-----+
| Does the laboratory have        | There is adequate & safe    | Y N |
| adequate ventilation? If smears | ventilation                 |     |
| are performed in front of an    |                             |     |
| open window, are technicians    |                             |     |
| aware of air flow direction and |                             |     |
| potential for danger?           |                             |     |
+---------------------------------+-----------------------------+-----+
| Which disinfectant is used?     | An NTP approved             | Y N |
|                                 | disinfectant active against |     |
|                                 | TB is used                  |     |
+---------------------------------+-----------------------------+-----+
| Have there been any shortages   | An adequate supply of       | Y N |
| of disinfectant supply in the   | disinfectant is available   |     |
| past three months?              |                             |     |
+---------------------------------+-----------------------------+-----+
| How often are work areas        | Work areas are cleaned at   | Y N |
| cleaned with disinfectant?      | least daily                 |     |
+---------------------------------+-----------------------------+-----+
| How are wire loops cleaned?     | A sand bucket with Lysol or | Y N |
|                                 | 70% ethanol is used to      |     |
|                                 | clean wire loops prior to   |     |
|                                 | flaming                     |     |
+---------------------------------+-----------------------------+-----+
| How are used slides disposed    | Used slides are properly    | Y N |
| of? Are slides ever reused?     | disposed of (boiled or      |     |
|                                 | buried)                     |     |
|                                 |                             |     |
|                                 | If slides are reused, the   |     |
|                                 | are properly disinfected    |     |
|                                 | and cleaned, and never      |     |
|                                 | reused for AFB microscopy.  |     |
+---------------------------------+-----------------------------+-----+
| How are used sputum containers  | Sputum containers used only | Y N |
| disposed of? Are sputum         | one time.                   |     |
| containers ever reused?         |                             | Y N |
| (Supervisor should check waste  | Used containers are burned  |     |
| disposal site to ensure proper  | or properly buried.         |     |
| burial)                         |                             |     |
+---------------------------------+-----------------------------+-----+
| Observe biohazard waste bin     | A biohazard waste bin with  | Y N |
|                                 | a lid is available          |     |
+---------------------------------+-----------------------------+-----+
| Are workers wearing lab coats?  | Lab coats are worn while    | Y N |
|                                 | working in the laboratory   |     |
+---------------------------------+-----------------------------+-----+
| Are lab coats removed prior to  | Lab coats are not worn      | Y N |
| leaving the laboratory?         | outside the laboratory      |     |
+---------------------------------+-----------------------------+-----+
| Are gloves used in the          | If gloves are available,    | Y N |
| laboratory? Are they used       | they are used in accordance |     |
| properly?                       | with safe work practice     |     |
|                                 | recommendations             |     |
+---------------------------------+-----------------------------+-----+
| Do workers wash their hands     | Proper handwashing          | Y N |
| after working with sputum?      | procedures are followed     |     |
+---------------------------------+-----------------------------+-----+
| Does laboratory appear clean    | Lab is clean, layout is     | Y N |
| and in good working order?      | adequate to ensure safe     |     |
|                                 | practices                   |     |
+---------------------------------+-----------------------------+-----+

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Action required
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**5. Laboratory Request Form, Laboratory Register, Laboratory Reports**

+---------------------------------+-----------------------------+-----+
| **Observe and Question**        | **Indicator**               |     |
+---------------------------------+-----------------------------+-----+
| Are the NTP approved laboratory | NTP approved laboratory     | Y N |
| request forms used for every    | request forms are used for  |     |
| patient?                        | every patient               |     |
+---------------------------------+-----------------------------+-----+
| Are laboratory request forms    | Laboratory request forms    | Y N |
| submitted with complete         | are submitted with complete |     |
| information?                    | information                 |     |
+---------------------------------+-----------------------------+-----+
| Is the laboratory register      | Laboratory register is      | Y N |
| present, and all columns        | present                     |     |
| completed properly?             |                             | Y N |
|                                 | Laboratory register is      |     |
|                                 | properly complete and       |     |
|                                 | legible                     |     |
+---------------------------------+-----------------------------+-----+
| Are patient records in          | District TB cases appear in | Y N |
| laboratory register consistent  | Laboratory register         |     |
| with District Register?         |                             |     |
|                                 | If no, how many patients    |     |
| # (C                            | are missing?                |     |
| ompare 10 patients from the Lab | \_\_\_\_\_\_\_\_\_\_\_\_    |     |
| oratory Registry and determine  |                             |     |
|                                 |                             |     |
| if all 10 patients are listed   |                             |     |
| in the district register)       |                             |     |
+---------------------------------+-----------------------------+-----+
| When is result information      | Results entered into        | Y N |
| entered into the laboratory     | register daily              |     |
| register?                       |                             |     |
+---------------------------------+-----------------------------+-----+
| Are laboratory results recorded | Laboratory results are      | Y N |
| on the request form?            | recorded directly onto the  |     |
|                                 | form                        |     |
+---------------------------------+-----------------------------+-----+
| How soon are results reported   | Forms are sent back to the  | Y N |
| to the treatment center or      | treatment center or         |     |
| physician?                      | physician within two        | Y N |
|                                 | working days.               |     |
|                                 |                             |     |
|                                 | ## *Al                      |     |
|                                 | l three results are sent ba |     |
|                                 | ck within two working days* |     |
+---------------------------------+-----------------------------+-----+
| Are three specimens routinely   | Three specimens, including  | Y N |
| examined as recommended by      | spot, morning and spot are  |     |
| IUATLD?                         | examined for diagnosis of   |     |
|                                 | TB.                         |     |
+---------------------------------+-----------------------------+-----+

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Action required
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**6. Microscope**

+---------------------------------+-----------------------------+-----+
| **Observe and Question**        | **Standard**                |     |
+---------------------------------+-----------------------------+-----+
| Is microscope present?          | At least one functional     | Y N |
|                                 | microscope is available     |     |
| # Adequate n                    |                             | Y N |
| umber of microscopes available? | Sufficient number of        |     |
|                                 | microscopes is available to |     |
|                                 | manage workload             |     |
+---------------------------------+-----------------------------+-----+
| Is the microscope functioning   | Supervisor can observe a    | Y N |
| properly?                       | clear image when looking    |     |
|                                 | through the microscope at a |     |
|                                 | random smear.               |     |
+---------------------------------+-----------------------------+-----+
| Is the stage mechanism          | Stage can be moved properly | Y N |
| functioning?                    |                             |     |
+---------------------------------+-----------------------------+-----+
| Is adequate light source        | Functional light bulb and   | Y N |
| present?                        | electricity, or microscope  |     |
|                                 | is located near adequate    |     |
|                                 | light source                |     |
+---------------------------------+-----------------------------+-----+
| How is maintenance on the       | Microscope is under         | Y N |
| microscope performed?           | maintenance contract or     |     |
|                                 | there is evidence of        |     |
|                                 | routine maintenance.        |     |
+---------------------------------+-----------------------------+-----+

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Action Required
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**7. Storage of slides for External Quality Assessment**

  ---------------------------------- ------------------------------ ------
  **Observe and Question**           **Standard**                   

  Are ALL slides kept as required by Slides are kept for EQA,       Y N
  the NTP EQA program?               supervisor is able to retrieve 
                                     all slides identified from the 
                                     laboratory register for EQA.   

  Are slides kept in storage boxes?  Slides are kept in storage     Y N
                                     boxes                          

  Are slides cleaned with xylene     Slides are cleaned with xylene Y N
  before storage, or are slides      before storage, or are stored  
  stored in boxes so that oil can    in boxes so that oil can drain 
  drain without contaminating other  without touching or            
  slides?                            contaminating other slides?    
  ---------------------------------- ------------------------------ ------

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Action Required
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**8. Staff Training**

  --------------------------------------------------------- -------------
  Has there been any change in staff since last supervisory Y N
  visit?                                                    

  Has new staff received proper training, as required by    Y N
  the NTP?                                                  

  If training requirements are not defined by NTP, has each Y N
  staff member participated in refresher training within    
  past two years?                                           

  Have results of rechecking been received by peripheral    Y N
  lab?                                                      

  Have results of rechecking or panel testing been          Y N
  acceptable?                                               

  If no, have any problems been identified through          Y N
  Rechecking or Panel Testing indicating there is a need    
  for additional training/refresher course?                 
  --------------------------------------------------------- -------------

Y N

Explain any need for additional training
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**9. Workload**

  ---------- ------------ ----------------------- ------------- -----------
  Number of               Number of suspects      Number of     
  smears                  smears last quarter     follow up     
  last                                            smears last   
  quarter                                         quarter       

  Total:                  Total:                  Total:        

  \# Pos:    \# Neg:                              \# Pos:       \# Neg:
  ---------- ------------ ----------------------- ------------- -----------

Average number of smears read by each technician per day?

**THE FOLLOWING EVALUATION QUESTIONS SHOULD ONLY BE COMPLETED BY
SUPERVISORY LABORATORY STAFF**

**10. Collection of Sputum Samples**

+---------------------------------+-----------------------------+-----+
| **Observe and Question**        | **Standard**                |     |
+---------------------------------+-----------------------------+-----+
| Is lab technician responsible   | If yes, complete all        | Y N |
| for collecting specimens?       | questions in this section   |     |
|                                 |                             |     |
|                                 | If no, skip to section 11   |     |
+---------------------------------+-----------------------------+-----+
| Ask the technician to describe  | Patients receive adequate   | Y N |
| the instructions for producing  | instruction to produce      |     |
| sputum that are given to        | sputum rather than saliva   |     |
| patient                         |                             |     |
+---------------------------------+-----------------------------+-----+
| Is the quality of specimen      | Specimen is evaluated       | Y N |
| checked?                        | visually for presence of    |     |
|                                 | sputum                      |     |
+---------------------------------+-----------------------------+-----+
| When the patient produces       | Smears are not prepared     | Y N |
| saliva, is a repeat specimen    | from specimens recognized   |     |
| collected?                      | as saliva.                  | Y N |
|                                 |                             |     |
|                                 | Repeat specimens are        |     |
|                                 | requested.                  |     |
+---------------------------------+-----------------------------+-----+
| How many pre-treatment          | Three specimens are         | Y N |
| specimens are routinely         | routinely collected,        |     |
| collected for diagnosis?        | following IUATLD and WHO    |     |
|                                 | guidelines for Spot,        |     |
| How many specimens are          | Morning & Spot collection.  |     |
| routinely collected for         |                             |     |
| treatment follow-up?            |                             |     |
+---------------------------------+-----------------------------+-----+

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**11. Smearing and Staining Procedures**

+-------------------------------+-------------------------+-----+-----+
| **Observe and Question**      | **Standard**            |     |     |
+-------------------------------+-------------------------+-----+-----+
| Does technician verify that   | Containers are labeled  |     | Y N |
| container is properly         | with the health center  |     |     |
| labeled?                      | code and the patient    |     |     |
|                               | identification on the   |     |     |
|                               | side of the container,  |     |     |
|                               | not on the lid.         |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are new slides used for       | New slides are used for |     | Y N |
| sputum AFB smears? Are slides | AFB microscopy.         |     |     |
| cleaned prior to use?         |                         |     | Y N |
|                               | Slides are cleaned      |     |     |
|                               | prior to use if greasy. |     |     |
+-------------------------------+-------------------------+-----+-----+
| How are slides labeled?       | Slides are labeled with |     | Y N |
|                               | laboratory code, serial |     |     |
|                               | number and sequence     |     |     |
|                               | identifier.             |     |     |
+-------------------------------+-------------------------+-----+-----+
| How often is Carbol Fuchsin   | Carbol Fuchsin is       |     | Y N |
| filtered?                     | always filtered before  |     |     |
|                               | use                     |     |     |
+-------------------------------+-------------------------+-----+-----+
| How often is Methylene Blue   | Methylene Blue is       |     | Y N |
| filtered?                     | filtered at least once  |     |     |
|                               | a month or more often   |     |     |
|                               | if precipitate is noted |     |     |
|                               | in smears               |     |     |
+-------------------------------+-------------------------+-----+-----+
| Is the wire loop cleaned in   | The wire loop is        |     | Y N |
| sand and sterilized by        | sterilized by flaming   |     |     |
| flaming after every smear?    | after every smear OR A  |     | Y N |
| **or** Is a new wooden stick  | new wooden stick is     |     |     |
| used to prepare each smear?   | used to prepare each    |     |     |
|                               | smear                   |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are smears air dried          | Smears are completely   |     | Y N |
| completely prior to fixing?   | *air dried* prior to    |     |     |
|                               | fixing                  |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are slides properly heat      | Slides are heat fixed   |     | Y N |
| fixed?                        | by passing 3-5 times    |     |     |
|                               | through flame           |     |     |
+-------------------------------+-------------------------+-----+-----+
| How many slides are usually   | *A maximum of* 10-12    |     | Y N |
| stained in a batch?           | specimens are processed |     |     |
|                               | at one time             |     |     |
+-------------------------------+-------------------------+-----+-----+
| What is the staining          | Slides are stained with |     | Y N |
| procedure used by the         | hot, steaming CF for 5  |     |     |
| technician? How long are      | minutes                 |     | Y N |
| slides stained with CF and    |                         |     |     |
| MB? How are slides            | Stain is not permitted  |     | Y N |
| decolorized?                  | to dry on the slide     |     |     |
|                               |                         |     | Y N |
|                               | Slides are decolorized  |     |     |
|                               | for 3 minutes, repeat   |     | Y N |
|                               | decolorization is       |     |     |
|                               | performed only when     |     |     |
|                               | needed, slides are not  |     |     |
|                               | over-decolorized        |     |     |
|                               |                         |     |     |
|                               | Slides are              |     |     |
|                               | counterstained with MB  |     |     |
|                               | for 1 minute            |     |     |
+-------------------------------+-------------------------+-----+-----+
| How often are microscope      | Microscope objective is |     | Y N |
| lenses cleaned with lens      | wiped with lens tissue  |     |     |
| tissue?                       | after every slide       |     |     |
|                               | examination             |     |     |
+-------------------------------+-------------------------+-----+-----+
| How many fields are examined  | The microscopist takes  |     | Y N |
| to report a negative smear?   | at least 5 minutes      |     |     |
|                               | *and* examine 100       |     |     |
|                               | fields                  |     |     |
+-------------------------------+-------------------------+-----+-----+
| How many fields are examined  | An adequate number of   |     | Y N |
| to report a positive smear?   | fields is examined to   |     |     |
|                               | provide accurate        |     |     |
|                               | quantitation. For high  |     |     |
|                               | positives, this may be  |     |     |
|                               | 20-50 fields, for low   |     |     |
|                               | positives, 100 fields   |     |     |
|                               | should be read.         |     |     |
+-------------------------------+-------------------------+-----+-----+
| How are results reported?     | Results are consistent  |     | Y N |
|                               | with *NTP*              |     |     |
|                               | recommendations for     |     |     |
|                               | grading and reporting   |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are known positive and        | Control smears are      | Da  |     |
| negative smears included as   | included.               | ily |     |
| an internal control? Observe  |                         |     |     |
| availability of sufficient    |                         | E   |     |
| quantity of control slides.   |                         | ach |     |
|                               |                         | new |     |
|                               |                         | ba  |     |
|                               |                         | tch |     |
|                               |                         | of  |     |
|                               |                         | st  |     |
|                               |                         | ain |     |
|                               |                         |     |     |
|                               |                         | Ne  |     |
|                               |                         | ver |     |
+-------------------------------+-------------------------+-----+-----+

Explain any problems or deficiencies
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+-------------------------------+-------------------------+-----+-----+
| **Observe and Question**      | **Standard**            |     |     |
+-------------------------------+-------------------------+-----+-----+
| Does technician verify that   | Containers are labeled  |     | Y N |
| container is properly         | with the health center  |     |     |
| labeled?                      | code and the patient    |     |     |
|                               | identification on the   |     |     |
|                               | side of the container,  |     |     |
|                               | not on the lid.         |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are new slides used for       | New slides are used for |     | Y N |
| sputum AFB smears? Are slides | AFB microscopy.         |     |     |
| cleaned prior to use?         |                         |     | Y N |
|                               | Slides are cleaned      |     |     |
|                               | prior to use if greasy. |     |     |
+-------------------------------+-------------------------+-----+-----+
| How are slides labeled?       | Slides are labeled with |     | Y N |
|                               | laboratory code, serial |     |     |
|                               | number and sequence     |     |     |
|                               | identifier.             |     |     |
+-------------------------------+-------------------------+-----+-----+
| How often is Carbol Fuchsin   | Carbol Fuchsin is       |     | Y N |
| filtered?                     | always filtered before  |     |     |
|                               | use                     |     |     |
+-------------------------------+-------------------------+-----+-----+
| How often is Methylene Blue   | Methylene Blue is       |     | Y N |
| filtered?                     | filtered at least once  |     |     |
|                               | a month or more often   |     |     |
|                               | if precipitate is noted |     |     |
|                               | in smears               |     |     |
+-------------------------------+-------------------------+-----+-----+
| Is the wire loop cleaned in   | The wire loop is        |     | Y N |
| sand and sterilized by        | sterilized by flaming   |     |     |
| flaming after every smear?    | after every smear OR A  |     | Y N |
| **or** Is a new wooden stick  | new wooden stick is     |     |     |
| used to prepare each smear?   | used to prepare each    |     |     |
|                               | smear                   |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are smears air dried          | Smears are completely   |     | Y N |
| completely prior to fixing?   | *air dried* prior to    |     |     |
|                               | fixing                  |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are slides properly heat      | Slides are heat fixed   |     | Y N |
| fixed?                        | by passing 3-5 times    |     |     |
|                               | through flame           |     |     |
+-------------------------------+-------------------------+-----+-----+
| How many slides are usually   | *A maximum of* 10-12    |     | Y N |
| stained in a batch?           | specimens are processed |     |     |
|                               | at one time             |     |     |
+-------------------------------+-------------------------+-----+-----+
| What is the staining          | Slides are stained with |     | Y N |
| procedure used by the         | hot, steaming CF for 5  |     |     |
| technician? How long are      | minutes                 |     | Y N |
| slides stained with CF and    |                         |     |     |
| MB? How are slides            | Stain is not permitted  |     | Y N |
| decolorized?                  | to dry on the slide     |     |     |
|                               |                         |     | Y N |
|                               | Slides are decolorized  |     |     |
|                               | for 3 minutes, repeat   |     | Y N |
|                               | decolorization is       |     |     |
|                               | performed only when     |     |     |
|                               | needed, slides are not  |     |     |
|                               | over-decolorized        |     |     |
|                               |                         |     |     |
|                               | Slides are              |     |     |
|                               | counterstained with MB  |     |     |
|                               | for 1 minute            |     |     |
+-------------------------------+-------------------------+-----+-----+
| How often are microscope      | Microscope objective is |     | Y N |
| lenses cleaned with lens      | wiped with lens tissue  |     |     |
| tissue?                       | after every slide       |     |     |
|                               | examination             |     |     |
+-------------------------------+-------------------------+-----+-----+
| How many fields are examined  | The microscopist takes  |     | Y N |
| to report a negative smear?   | at least 5 minutes      |     |     |
|                               | *and* examine 100       |     |     |
|                               | fields                  |     |     |
+-------------------------------+-------------------------+-----+-----+
| How many fields are examined  | An adequate number of   |     | Y N |
| to report a positive smear?   | fields is examined to   |     |     |
|                               | provide accurate        |     |     |
|                               | quantitation. For high  |     |     |
|                               | positives, this may be  |     |     |
|                               | 20-50 fields, for low   |     |     |
|                               | positives, 100 fields   |     |     |
|                               | should be read.         |     |     |
+-------------------------------+-------------------------+-----+-----+
| How are results reported?     | Results are consistent  |     | Y N |
|                               | with *NTP*              |     |     |
|                               | recommendations for     |     |     |
|                               | grading and reporting   |     |     |
+-------------------------------+-------------------------+-----+-----+
| Are known positive and        | Control smears are      | Da  |     |
| negative smears included as   | included.               | ily |     |
| an internal control? Observe  |                         |     |     |
| availability of sufficient    |                         | E   |     |
| quantity of control slides.   |                         | ach |     |
|                               |                         | new |     |
|                               |                         | ba  |     |
|                               |                         | tch |     |
|                               |                         | of  |     |
|                               |                         | st  |     |
|                               |                         | ain |     |
|                               |                         |     |     |
|                               |                         | Ne  |     |
|                               |                         | ver |     |
+-------------------------------+-------------------------+-----+-----+

**12. Onsite Rechecking**

Laboratory supervisor should re-read at least three positive and
negative smears during the on-site visit.

+---+------+----------+--------+--------+--------+-------+------------+
|   | S    | Result   | Result | St     | St     | S     | Thickness  |
|   | lide |          |        | aining | aining | putum | and size   |
|   | No.  | Pe       | Supe   |        |        | or    |            |
|   |      | ripheral | rvisor | AFB    | Back   | S     | of smear   |
|   |      | Lab      |        |        | ground | aliva |            |
+---+------+----------+--------+--------+--------+-------+------------+
| \ |      |          |        |        |        |       |            |
| + |      |          |        |        |        |       |            |
+---+------+----------+--------+--------+--------+-------+------------+
| \ |      |          |        |        |        |       |            |
| + |      |          |        |        |        |       |            |
+---+------+----------+--------+--------+--------+-------+------------+
| \ |      |          |        |        |        |       |            |
| + |      |          |        |        |        |       |            |
+---+------+----------+--------+--------+--------+-------+------------+
| \ |      |          |        |        |        |       |            |
| - |      |          |        |        |        |       |            |
+---+------+----------+--------+--------+--------+-------+------------+
| \ |      |          |        |        |        |       |            |
| - |      |          |        |        |        |       |            |
+---+------+----------+--------+--------+--------+-------+------------+
| \ |      |          |        |        |        |       |            |
| - |      |          |        |        |        |       |            |
+---+------+----------+--------+--------+--------+-------+------------+

**13. Rechecking and/or Panel Testing**

Have results of rechecking or panel testing been acceptable according to
performance expectations set by NTP*?* Y N

If no, have any problems been identified through Rechecking or Panel
Testing indicating there is a need for corrective action?

Explain any need for corrective action
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Has corrective action been adequately implemented? Y N

If no, explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**14. On-Site Evaluation Summary**

> List any MAJOR problems identified during the on-site visit:
>
> A. Operational Problems:
>
> B. Technical Problems:

15\. Name of person completing On-Site
Evaluation:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

16\. Signature of Laboratory Supervisor:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_