Fill up, print and fax to: Atty: Nicolas B. Lutero III, CESO III, Director IV, Bureau of Health Facilities and Services at Tel. # 781-4179
Memo For :
From :
Date Submitted :
Subject :
Date of Incidence:
Incidence :	Report on how it happened
Short Branch Name
Transaction #
Accession #
Note: For errors in results, specify drug/metabolite.
Remedial Action Done:	State the action (s) done
Name & Signature of Analyst
Name & Signature of Laboratory Head
TELEPHONE #		FAX #.	Email Address:

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BHFS, DOH:	Approved For Correction(s)	Disapproved for Correction(s)
REMARKS:
NAME AND SIGNATURE:		POSITION: DATE:

IMS, DOH:	Corrected      Cannot be Corrected    Disapproved
REMARKS:
NAME AND SIGNATURE:		POSITION: DATE: