DOC3226 / ERNDIM: ACYLCARNITINES INSERUMEducational Participation Applicant Declaration Form
/ ERNDIM Administration Office
Manchester Centre for Genomic Medicine,
6th Floor St Mary's Hospital
Oxford Road, Manchester,
M13 9WL, United Kingdom
Tel: +44 161 276 6741; Fax: +44 161 850 1145
Email:
APPLICANT DECLARATION FORM
for Educational Participation in the Acylcarnitines in Serum Scheme
  • Educational Participation is open to laboratories that are participating in an EQA scheme to help with setting up a new test but are not yet offering a clinical service.
  • Educational Participation is available for all ERNDIM EQA schemes EXCEPT the Diagnostic Proficiency Testing scheme.
  • Applications for Educational Participation in a scheme will only be accepted from laboratories who have already registered to participate in the EQA Scheme.
  • Please use this form for the Acylcarnitines in serum scheme only. Separate forms are available for the other Quantitative schemes and the Qualitative schemes.
  • A separate form must be completed for each scheme for which you wish to be an Educational Participant.
  • All sections of the form must be completed. Please use block capitals.

1. Name of EQA scheme: / ACYLCARNITINES (SERUM)
2. From the list below, please select the individual analytes which you DO NOT provide a service for:
Free carnitine (C0) / Acetylcarnitine (C2) / Propionylcarnitine (C3)
Butyrylcarnitine (C4) / Tiglylcarnitine (C5:1) / Isovalerylcarnitine (iC5)
(2R)-3-Hydroxyisovaleroyl Carnitine (3-OH-iC5) / Hexanoylcarnitine (C6)
Octanoylcarnitine (C8) / Decanoylcarnitine (C10) / Cis-5-Tetradecenoylcarnitine (cis-5-C14:1)
Tetradecanoylcarnitine (C14) / Palmitoylcarnitine (C16) / 3-Hydroxyhexadecanoyl-L-carnitine (3-OH-C16)
Oleoylcarnitine (cis-9-C18:1) / Stearoylcarnitine (C18) / 3-Hydroxystearoylcarnitine (3-OH-C18)
Malonylcarnitine (C3DC) / Methylmalonylcarnitine (C4DC) / Glutarylcarnitine (C5DC)
3. ERNDIM Ref. No. (ERNxxxx):
4. Person named as primary ERNDIM contact:
5. Laboratory Name:
6. Parent Institution:
7. Address:
City:
Postcode:
Country:
Terms and conditions
  • For Educational participants:
– Submitted results will be assessed so feedback can be given.
– Poor performance will not be recorded so Performance Support letters will not be sent.
– Certificates of Participation will not be issued.
– The cost of registering as an Educational Participant for a scheme will be the same as the full EQA scheme price.
– Participation as an Educational participant will be limited to 2 years after which laboratories will have to register as a full EQA participant.
  • As the number of Educational Participants per scheme is limited priority will be given to existing Educational Participants and then newer scheme participants.

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8.Please read the terms and conditions on page 1 and tick each box next to statements below if you agree with them(please note we will only consider applications that agree with all of these statements).
8. a. I agree with the terms and conditions of Educational Participation specified above
8. b. I certify that this laboratory does not provide a clinical service for a test covered by any of the analytes specified initem2., which are included in the EQA scheme specified in item 1.
8. c. I agree that it is the responsibility of this laboratory to inform ERNDIM at the earliest opportunity if the circumstance specified in statement 8.b. should change
9. Head of Laboratory signature
Name:
Signature: / Date:
Important note: The complete history of this document including its author, authoriser(s) and revision date, can be found on Q-Pulse
Controlled Document – DO NOT PHOTOCOPY
ERNDIM (EuropeanResearchNetwork for evaluation and improvement of screening,Diagnosis and treatment ofInherited disorders ofMetabolism / Document printed on 02/11/2018 10:06 by Sara Gardner
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