Referral Laboratory Evaluation Checklist template
A form in the Referral Laboratories and Consultants procedure (PR04), mapped to ISO 15189:2022 clause 6.8. Fill it in whenever the task occurs. Used by the quality-management team.
FormISO 15189 · 6.8As needed
Calculated automaticallyRed = outside limits
Your LaboratoryReferral Laboratory Evaluation Checklist | YL-QM-FRM-04-F01 v1.0
Record: Referral Laboratory Evaluation Checklist — October 2026
Referral Laboratory NameT. Moyo
Date2026-10-01
Location / Country35
Evaluated byT. Moyo
| No. | Evaluation Criterion | Met? (Y/N/Partial) | Evidence / Document Reference | Score (0-3) | Weight | Weighted Score | Gap / Observation | Action Required | Comments |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Accreditation status (ISO 15189 / equivalent) | NC-26-001 | 77 | 3 | 96 | Within limits | None required | Within limits | |
| 2 | Scope covers required tests | NC-26-002 | 97 | 3 | 96 | None required | |||
| 3 | Proficiency testing / EQA participation demonstrated | NC-26-003 | 66 | 2 | 81 | None required | |||
| 4 | TAT acceptable and documented | NC-26-004 | 81 | 2 | 75 | Within limits | Investigated and repeated: within limits | Within limits | |
| 5 | Specimen transport / cold chain arrangements adequate | NC-26-005 | 73 | 2 | 76 | None required | |||
| 6 | Results reporting format acceptable | NC-26-006 | 94 | 1 | 72 | None required | |||
| 7 | Confidentiality agreement in place / willing to sign | NC-26-007 | 95 | 2 | 95 | Within limits | None required | Within limits | |
| 8 | Financial / billing arrangements clear | NC-26-008 | 61 | 1 | 76 | None required | |||
| 9 | Communication responsiveness adequate | NC-26-009 | 75 | 1 | 63 | None required | |||
| 10 | Previous performance / reference checks satisfactory | NC-26-010 | 96 | 2 | 95 | Within limits | None required | Within limits |
Max = 60 | Pass ≥ 36 (60%)
Decision (Approve / Reject / Conditional)
… 2 more rows continue on the next page
Sign-off
| Role | Name | Signature | Date |
|---|---|---|---|
| Completed by | |||
| Reviewed by |
Shaded cells are calculated automatically. Values in red are outside their limits. † marks a corrected value (see Corrections).
Controlled document. Printed copies are uncontrolled unless stamped.Page 1
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What it records
- Evaluation Criterion
- Met? (Y/N/Partial)
- Evidence / Document Reference
- Score (0-3)
- Weight
- Weighted Score
- Gap / Observation
- Action Required
- Comments
Instructions on the form
- Max = 60 | Pass ≥ 36 (60%)
Sign-off
- Completed by
- Reviewed by
Related templates
- Consultant Evaluation Checklist (PR04-F02)
- List of Approved Referral Laboratories and Consultants (PR04-F04)
- Sample Referral Log (PR04-F05)
- Guide: ISO 15189 documentation checklist
Clause references are to ISO 15189:2022; check them against your licensed copy of the standard.