Cytotechnologist/certified Histological Technician Form 4a - Certification Of Experience - The University Of The State Of New York The State Education Department - 2008 Page 2
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1
2Section II: Certification of Experience
Instructions to Clinical Laboratory Director: Complete items A and B, sign and date the affirmation and send both pages of this
form directly to the address at the end of this form. This form will not be accepted if returned by the applicant.
A. Qualifications
F Yes
F No
I am a Clinical Laboratory Director as defined below
Definition: A “Clinical Laboratory Director” means a “person who is responsible for administration of the technical and scientific
operation of a clinical laboratory or blood bank, including the supervision of procedures and reporting of findings of tests”
B. Experience Information
Name of applicant: _____________________________________________________________________________________________
(Item 3, page 1)
I am attesting that the applicant has practiced as a (check one): F cytotechnologist or F certified histological technician as follows:
_____________________________________________________________________________________________________________
Address of setting where experience took place
City
State
Zip Code
Dates of Experience (be sure to only report the appropriate hours, see item 5 on page 1):
From: _______ / _______ / _______ to _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Total clock hours practicing as a (check one): F cytotechnologist or F certified histological technician where I am a Clinical
Laboratory Director: ______________________
Cytotechnologist means a clinical laboratory practitioner who, pursuant to established and approved protocols of the Department of
Health, performs cytological procedures and examination and any other such tests including maintaining equipment and records and
performing quality assurance activities related to examination performance, and which require the exercise of independent judgement
and responsibility, as determined by the Department.
Certified histological technician means a clinical laboratory practitioner who pursuant to established and approved protocols of the
department of health performs slide based histological assays, tests, and procedures and any other such tests conducted by a clinical
histology laboratory, including maintaining equipment and records and performing quality assurance activities relating to procedure
performance on histological testing of human tissue and which requires limited exercise of independent judgement and is performed
under the supervision of a laboratory supervisor, designate by the director of a clinical laboratory or under the supervision of the director
of the clinical laboratory.
Affirmation
Clinical Laboratory Director
I declare and affirm under penalty of perjury that the statements made in the foregoing application, including any attached statements,
are true, complete and correct and that the experience I am attesting to meets the definition of practice as a (check one): F
cytotechnologist or F certified histological technician
Signature: ______________________________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
F Check here if you are
Print Name _____________________________________________________________________
attaching additional
information.
Address _______________________________________________________________________
Phone: __________________________________ Fax:__________________________________
E-mail: ________________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Clinical Laboratory Technology Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Cytotechnologist/Certified Histological Technician Form 4A, Page 2 of 2, (Rev. 9/08)
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