Manager

Histology Supervisor and Manager: please provide us with information about your facility volume and staffing.

NAME AND FACILITY

Name

First:

Last:

Facility Name:

Address:

City:

State:

Zip Code:

Phone:

FACILITY SIZE/VOLME

Number of hospital beds:

Number of pathology cases annually:

Number of cytology cases annually:

Number of autopsies performed annually:

Autopies performed on-site?

Yes No

Grossing performed on-site?

Yes No


STAFFING

Number of FTE in your Histology laboratory:

1-5 6-10 11-20 greater than 20

Number of FTE that are registered HT/HTL:

1-5 6-10 11-20 greater than 20

Do you have a Histology supervisor?

Yes No

Do you have a Lead Technician/Technologist?

Yes No

Before submitting this form, please type the color of the second character:
* Important