Laboratory Accreditation Confirmation Form

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LABORATORY ACCREDITATION CONFIRMATION FORM
Participation NEQAS / laboratory accreditation
This form is used to confirm that your Laboratory fulfils conditions as required by the Medicines and Healthcare Products Regulatory Agency (MHRA) entailing that Full Blood Count (FBC) results that are provided to the Zaponex® Treatment Access System (ZTAS®) conform to adequate quality standards. ZTAS is a controlled access program in place to mitigate risks associated with clozapine and a requirement of the Zaponex licence. ZTAS monitors blood results (WBC, Neutrophils, Eosinophils and Platelets) of all patients treated with Zaponex. A laboratory used for ZTAS blood testing is required to participate in the National External Quality Assurance Scheme (NEQAS) and/or can demonstrate a current and valid laboratory accreditation covering FBC tests (Haematology). Please complete all sections.
We will use any personal information provided on this form in accordance with the terms explained in the ZTAS privacy notice which is available from the ZTAS website www.ztas.co.uk.

Leyden Delta/ZTAS was unable to find proof of a current accreditation via online UKAS registers for your Laboratory. We are aware accreditation is reviewed on a regular basis. We kindly ask you to confirm participation in the NEQAS and/or proof of a valid relevant accreditation for FBC tests for your laboratory.

Thank you in advance for your help. Should you have any questions, please contact ZTAS on 0207 365 5842. Leyden Delta; ZTAS team

Details to be completed
Name laboratory
Location testing ZTAS FBC samples Postcode
This laboratory participates in/is accredited to (please indicate the appropriate options and their details).
NEQAS NEQAS Reference number
UKAS (ISO 15189/Haematology) UKAS Reference Number
Other* Please specify
Please also send a copy of a letter that proves participation in, or accreditation to the relevant standard to the ZTAS (clozapine monitoring service) by email on info@ztas.co.uk.
The information/letter should contain reference to the name of the Laboratory that you have completed at the top of this Form.
Form completed by
Laboratory manager Name
Pharmacist Name
  GPC/PNI

Contact phone number
Email address
I certify that, to the best of my knowledge, the information provided is true and accurate.

Submission Date Signature
02-Dec-2022

PSS.F03.S07.001