Sample Auditor Checklist

Sample Auditor Checklist - ICANL AUDIT REVIEWERS WORKSHEET...

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You can use the hyperlinks below to jump to any point in the document--just click on the line to go directly to that question. Click on the 'Top' links on the right-hand side of the document to return here. Lab Overview ICANL AUDIT REVIEWER'S WORKSHEET Conflict of Interest Statement I acknowledge that I have received and read ICANL’s for audit reviewers. I do not have any actual, apparent or potential conflicts of interest with the laboratory below, which are not listed on the Disclosure Statement . I agree to abide by the terms of ICANL’s . I understand that it is my responsibility to inform ICANL in writing of any change in circumstances relating to the . The audit reviewer has an obligation to maintain the confidentiality of patient information. The audit reviewer may not disclose information regarding the accreditation status of a laboratory, or release confidential patient information pertaining to any audit they have reviewed. I agree to indemnify the ICANL for the costs of any claims arising out of my services to the ICANL as an audit reviewer, if pursuant to a violation by me of the limited to my failure to disclose an actual or apparent conflict of interest or any authorized disclosure of involvement with this audit. Save Work Send to ICANL Check for Completeness Information about this Application: Test Lab Annual Vol. Quality, MD RMPI: 150 Application #: 1000 ERNA: 150 Reviewer: Mary Beth Farrell GNM: 234 # of Sites: 3 PET: 150 First-Time application Lab Type: Private Office Board Certified Physicians: 1 Med Staff: 1 CBNC Certified Physicians: 1 Tech Staff: 1 Information about this Site: Site Number: 1 Test Lab 123 Accreditation Lane Quality, MD 12345 Areas of Accreditation applying for: Nuclear cardiology - Myocardial perfusion imaging (MPI) Nuclear cardiology - Equilibrium radionuclide angiography (ERNA) Gastrointestinal system imaging Skeletal system imaging Pulmonary system imaging PET Oncologic imaging Standards Evaluation of Compliance with Standards Meets Standard? Page 1 of 5 ICANL AUDIT REVIEWER’S WORKSHEET 3/26/2008 file://C:\Documents and Settings\farrell\My Documents\SVR 1000-1 R10810.html
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Yes (compliant) No (not compliant) - requires site visitor comments Partially compliant = requires site visitor comments Part A: Structure and Organization I have read and agree to the Conflict of Interest statement above. (If you cannot click 'Agree,' please contact the ICANL staff and return the audit materials immediately.) Agree Disagree A3 Physical Facilities A3.1 Adequate facilities are provided for: A3.1.2 Does the lab indicate that there are adequate facilities for radiopharmaceutical receipt, preparation, calibration, storage, and disposal which are secured when staff are not present? Yes No Partially A3.1.3
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Sample Auditor Checklist - ICANL AUDIT REVIEWERS WORKSHEET...

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