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NAACLS Volunteer Information Form

Page One

1. Please fill out the form below.

First Name

Last Name

Credentials

Title

Institution Name

Street Address

Apt/Suite/Office

City

State

Zipcode

Country

Email Address

Phone Number

Fax Number

Mobile Phone

URL

2. What type(s) of program(s) are you currently involved with?

3. What position(s) have you held that qualifies you to volunteer for NAACLS?

Space Cell	Currently	Formerly
Program Director of NAACLS Accredited/Approved Program	Currently	Formerly
Faculty Member involved with NAACLS Accredited/Approved Program	Currently	Formerly
Administration involved with NAACLS Accredited/Approved Program	Currently	Formerly
Other Clinical Laboratory Professional involved with NAACLS Accredited/Approved Program	Currently	Formerly

4. What type of institution are you employed by?

5. What type(s) of program(s) would you be interested in reviewing?

6. Are you fluent in Spanish?

7. If you will be driving a vehicle while conducting NAACLS business, do you hold primary insurance?

8. Do you agree to provide NAACLS with the name, contact information, and policy number of your insurance in the event of an incident?

9. Did you change your position at all in the last year?

10. What months during the course of the year are your preferred months to volunteer?

Volunteers are always offered opportunities before they are given assignments, so don't worry if your schedule may end up changing - we will ask first!

11. Please tell us about your NAACLS related volunteer experiences:

Number of times serving as Site Visit Team Coordinator:
Number of times serving as Site Visit Team Member:
Number of times serving as Site Visit Educator Generalist:
Number of times serving as Self-Study Reviewer:
Number of NAACLS Workshops you have attended:

12. Conflicts of Interest: Please list institutions/programs with which you or your employer have been or are currently affiliated with, and therefore would not be able to review.

13. Any additional addresses you may wish to be contacted at?

14. Would you be interested in being a VIP? (Volunteer mentor for Initial Program directors)To apply you must comply with the following criteria: 1) VIP Candidate must have conducted at least one accreditation site visit as a Team Coordinator (accredited programs only), and must have reviewed at least one self-study as a Self-Study, and 2) VIP Candidate must have at least 3 years of experience as program director of a NAACLS Accredited/Approved Program, including having gone through at least one successful accreditation/approval review resulting in the maximum allowable award.

Yes, I'm Interested!!
No, thank you.

15. I agree to download and read through the NAACLS Volunteer Manual. *This question is required.