Request for New Test Laboratory Manual Entry

All new test development must be evaluated to ensure that it meets institutional goals. Submissions will be reviewed monthly and feedback will be provided to the requestor. All molecular tests will be reviewed and approved by the Molecular Diagnostics Oversight Committee. All non-molecular tests will be reviewed and approved by the appropriate laboratory section director(s) and laboratory administration. Please complete all of the following required information, including the Requestor Information and Statement of Economic Interest. Select the "Submit Request" button at the end of the page to submit your request.

Requestor Information

Physician's Name:
Department:
Email address:
Phone number:
Test requested:
Category of Test
How did you learn of this test:	Name: Date: Other:
Impact on patient care/treatment:	Other:
References documenting clinical validity (two required)	Reference File 1: Reference File 2:
Would this replace a test(s) from the formulary if this new request is adopted?	Yes No
Who would utilize this test:
Anticipated volume (patients/year treated annually with this test):	Inpatient Outpatient
Required Turn Around Time (TAT):	Other:

Statement of Economic Interest

Requests for addition of a laboratory test to the Hospital Formulary are official University actions and subject to the University of California's Conflict of Interest policies. Therefore, medical staff members who initiate requests for addition of a test to the Hospital Formulary are required to disclose whether or not they have any financial interests in the company which manufactures the recommended testing reagents.

This form is designed to enable the Committee to be aware of any financial interests when it considers Formulary addition requests; it does not preclude medical staff members with such interests from making addition requests and will not preclude approval of the requested lab test for addition to the formulary. This information will become part of the Committee's records and will be accessible to Committee members only.

	In the past 24 months, have you or your Division received research funds or other financial support from a manufacturer of required reagents for this request laboratory test?
	Yes No

	In the past 24 months, have you or any close relative received any form of loan, gift, salary, honoraria or compensation for consulting services from the manufacturer? Have you or any close relative maintained any other financial interest (e.g. stock options) in the test’s manufacturer?
	Yes No

	Please indicate the nature of the financial support for the questions answered "Yes" above.