Form LDW-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 Laboratory for Drinking Water Analysis Name of Laboratory1 :____________________________________________________ Address of the Laboratory :____________________________________________________
No. & Street City/ Municipality Barangay Province Region

____________________________________________________ Telephone/ Fax No. Name of Head of the Laboratory Name of Owner Contact No. :____________________________________________________

:____________________________________________________ :____________________________________________________ :____________________________________________________

Classification According to Ownership : [ ] Government Service Capability

[ ] Private

: [ ] Bacteriological Analysis [ ] Chemical Analysis [ ] Physical Analysis [ ] Radiological Analysis : [ ] Initial [ ] Renewal Accreditation No. ____________ Date Issued ________________ Expiry Date _________________

Status of Application

Checklist of Application Documents

Please tick ( ) the appropriate boxes under column B or C. Items shaded are not required. B For Initial C For Renewal A Documents Notarized Application for Accreditation of Laboratory for Drinking Water Analysis (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 laboratory aide/ technician PRC ID/ PRC Board Certificate, if applicable PAM Registration, if applicable Certificate of Training/ Record of Work Experience 4.2. Proof of employment of head of the laboratory, analyst and laboratory aide/ technician List of Equipment/ Instrument (use attached form) Duly accomplished Assessment Tool (use attached form) Location Map for the laboratory building Photographs of the exterior and interior of the laboratory

1. 2. 3. 4.

5. 6. 7. 8.
1

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

Form LDW-COA-AF-2007 A Documents 9. Floor Layout with appropriate scale reflecting properly labeled areas to include spatial relationship with adjacent areas if present 10. DTI/ SEC Registration (for private laboratory) OR Issuance or Board Resolution (for government laboratory) 11. Quality Manual for Drinking Water Analysis B For Initial C For Renewal

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

______________________________, ____________, of legal age, __________, a resident of Civil Status Age Name ___________________________________________, 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 documents required for the Registration and Accreditation of Laboratories for Drinking Water Analysis pursuant to Administrative Order No. 2006-0024 Rules and Regulations Governing the Accreditation of Laboratories for Drinking Water Analysis.

I,

_________________________ 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___

Page 2 of 4

Form LDW-COA-AF-2007

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

Name

Designation/ Position

Highest Educational Attainment

PRC Reg. No./ PAM Reg. No.

Valid From To

Signature

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Form LDW-COA-AF-2007

List of Equipment, Reagent and Laboratory Ware2 Name of Laboratory :_________________________________________________________________________________________ Address of the Laboratory :_________________________________________________________________________________________

Test/ Method

Equipment Brand Name & Model Serial No. Quantity Date of Purchase

Reagent/ Media

Laboratory Ware and Materials

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