COLA Online Application

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Physical Address

Physical Address 2

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Physical City

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Physical State

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Physical Zip

Please provide the name and contact information for a key laboratory contact located at the physical location.

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Physical First Name

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Physical Last Name

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Physical Email Address

Physical Fax

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Physical Phone

Correspondence Address same as Physical?

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Correspondence Address

Correspondence Address 2

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Correspondence City

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Correspondence State

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Correspondence Zip

Please provide the name and contact information of the individual to whom COLA should direct correspondence regarding accreditation of the laboratory.

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Correspondence First Name

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Correspondence Last Name

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Correspondence Email Address

Correspondence Fax

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Correspondence Phone

Invoice Address same as Physical?

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Invoice Address

Invoice Address 2

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Invoice City

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Invoice State

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Invoice Zip

Please provide the name and contact information for the individual to whom invoices should be sent.

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Invoice First Name

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Invoice Last Name

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Invoice Email Address

Invoice Fax

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Invoice Phone

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Lab Director First Name

Lab Director Middle Name

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Lab Director Last Name

Lab Director Title

Lab Director Salutation

Lab Director Email Address

COLA ID's of Non-Waived Laboratories Overseen by this Laboratory Director

Current CLIA Certificate Type

CLIA Effective Date

Last Accreditation Organization

Other

Last Inspection Date

Is your LD a member of the following? Check all that apply.

AAFP ACP AMA OTHER

Other

Name of Laboratory Owner

Specialties & Sub-Specialties of Testing

Microbiology

Bacteriology

Mycobacteriology

Mycology

Parasitology

Virology

Immunology

Syphilis Serology

General Immunology

Chemistry

Routine

Urinalysis

Endocrinology

Toxicology

Hematology

Coagulation

Routine Hematology

Immunohematology

ABO & Rh Group

Antibody Detect (trans)

Antibody Detect (Nontran)

Antibody Identification

Compatibility Testing

Transfusion Services

Pathology

Histopathology

Oral

Cytology

Pathology Services

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Does your OR will your laboratory perform mass spectrometry analysis?

Yes No

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Does your OR will your laboratory include what is commonly called a 'blood bank' section, where blood products are stored and laboratory staff performs testing to identify compatible units of blood products for transfusion?

Yes No

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Does your facility perform any laboratory developed tests (also known as LDT, esoteric, or non-traditional tests)?

Yes No

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Does your OR will your laboratory process and/or examine histopathology or oral pathology specimens on the premises?

Yes No

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Does your OR will your laboratory process and/or examine gynecologic cytologic preparations on the premises?

Yes No

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Annual Test Volume

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Has your laboratory ever been enrolled in the COLA Accreditation Program?

Yes No

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Previous COLA ID #

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Have you ever been in the denial process?

Yes No

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Did you withdraw prior to having an initial survey performed by COLA?

Yes No

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Did you withdraw due to regulatory issues?

Yes No

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Does your previous accreditation organization have any outstanding investigations or actions in process, pending or being considered against your laboratory?

Yes No

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Have sanctions or investigations been implemented against your laboratory by any organization within the last 6 years? (such as Immediate jeopardy or Risk of Harm identified, requirement to cease testing, requirement for resurvey, complaint investigation, CLIA certificate limited or revoked)

Yes No

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Did your laboratory withdraw from the previous survey organization while actions or investigations against your laboratory were in progress?

Yes No

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Has the owner or operator of the laboratory ever owned or operated a laboratory whose CLIA certificate was revoked?

Yes No

If yes, when was the certificate revoked? NOTE: COLA will not accredit a laboratory whose owner/operator has had a CLIA certificate revoked in the preceding 24 months.

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Does the laboratory examine cytologic preparations on the premises?

Yes No

If yes, how long has the laboratory been examining cytology preparations?

How did you hear about COLA?

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I attest that, to the best of my knowledge and belief, all information in the above application is accurate and correct. I also agree to pay all applicable fees for the above-stated laboratory immediately after it is enrolled in COLA's Accreditation Program. I understand that once my fees are paid, I will receive a Verification of Enrollment Letter and access to COLAcentral. I understand that failure to pay fees can result in my laboratory's withdrawal from the program.