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Section 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”

This laboratory had a permit (license) issued under Title V, Article 5 of the NYS Public Health Law during the period in which the

F Yes

F No

applicant was employed?

B. Experience Information

I am attesting that ______________________________________________________________ has practiced as a certified histological

(Applicant’s Name)

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 histotechnology in the laboratory where I am a Clinical Laboratory Director: __________________________

I further attest that such experience was performed competently.

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 and competence I am attesting to meets the definition of practice as a certified

histological technician.

Signature: ______________________________________________________________________ Date _______ / _______ / _______

mo.

day

yr.

Print Name _____________________________________________________________________

F Check here if you are

attaching additional

Address _______________________________________________________________________

information.

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.

Certified Histological Technician Form 4C, Page 2 of 2, (Rev. 9/08)

Certified Histological Technician Form 4c - Certification Of Experience And Competence - 2008 Page 2

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