| Hospital
Name: |
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| POCT Coordinator(s) |
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| Phone# |
________________________________________________ |
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| Separate Licensed Sites: |
Site 1 |
Site 2 |
Site 3 |
| Type of License |
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| Hospital Bed Size |
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| # of Off-Campus Sites |
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| Lab FTE budgeted |
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| Lab FTE actual |
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| Nursing FTE budgeted |
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| Nursing FTE actual |
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| Section |
Test Type |
Equip/Mfg |
Annual
Test Volume |
Test Type |
Mfg |
Annual
Test Volume |
Test Type |
Mfg |
Annual
Test Volume |
| Hematology: |
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| Coagulation |
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| UA |
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| Microbiology |
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| Misc. |
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