Service Agreement Review Form template
A form in the Service Agreements procedure (PR03), mapped to ISO 15189:2022 clause 6.7. Fill it in whenever the task occurs. Used by the quality-management team.
FormISO 15189 · 6.7As needed
Calculated automaticallyRed = outside limits
Your LaboratoryService Agreement Review Form | YL-QM-FRM-03-F01 v1.0
Record: Service Agreement Review Form — October 2026
Service Provider / Facility
Review Date2026-10-01
| No. | Review Criterion | Met? (Y/N/Partial) | Evidence / Observation | Gap / Issue Identified | Action Required | Responsible Person | Target Date | Status | Comments |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Written agreement / MOU is in place and current | Within limits | Monthly QC review | None required | T. Moyo | 2026-10-01 | Closed | Within limits | |
| 2 | Scope of service is clearly defined | Equipment maintenance | None required | R. Naidoo | 2026-10-08 | In progress | |||
| 3 | TAT requirements are specified and met | Document review | None required | S. Dlamini | 2026-10-15 | Open | |||
| 4 | Confidentiality obligations are documented | Within limits | Competency assessment | Investigated and repeated: within limits | A. Mensah | 2026-10-22 | Closed | Within limits | |
| 5 | Competence of service provider is verified | Monthly QC review | None required | L. Banda | 2026-10-29 | Closed | |||
| 6 | Quality system / accreditation status confirmed | Equipment maintenance | None required | K. Otieno | 2026-11-05 | In progress | |||
| 7 | Communication channels are defined | Within limits | Document review | None required | T. Moyo | 2026-11-12 | Open | Within limits | |
| 8 | Dispute resolution mechanism is in place | Competency assessment | None required | R. Naidoo | 2026-11-19 | Closed | |||
| 9 | Agreement reviewed at least annually | Monthly QC review | None required | S. Dlamini | 2026-11-26 | Closed | |||
| 10 | Patient / sample identification requirements specified | Within limits | Equipment maintenance | None required | A. Mensah | 2026-12-03 | In progress | Within limits |
Overall Assessment
Agreement Continue? Y/N
… 4 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
A4 landscape · first page · showing 10 of 14 rowsExactly as LabToolkit Pro prints it — with your logo and colours
What it records
- Review Criterion
- Met? (Y/N/Partial)
- Evidence / Observation
- Gap / Issue Identified
- Action Required
- Responsible Person
- Target Date
- Status
- Comments
Sign-off
- Completed by
- Reviewed by
Related templates
Clause references are to ISO 15189:2022; check them against your licensed copy of the standard.