Clinical Laboratory Technologist/technician Form 4a - Certification Of Experience (Page 2 of 2) in pdf

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 the 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: _____________________________________________________________________________________________

I am attesting that the applicant has practiced as a (check one): F clinical laboratory technologist or F clinical laboratory 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 clinical laboratory technologist or F clinical laboratory technician in the laboratory

where I am a Clinical Laboratory Director: ______________________

Clinical laboratory technologist means a clinical laboratory practitioner who, pursuant to established and approved protocols of the

department of health, performs clinical laboratory procedures and examinations and any other tests or procedures conducted by a

clinical laboratory, including maintaining equipment and records, and performing quality assurance activities related to examination

performance, and which require the exercise of independent judgment and responsibility, as determined by the department.

Certified Clinical laboratory technician means a clinical laboratory practitioner who performs clinical laboratory procedures and

examinations pursuant to established and approved protocols of the department of health, which require limited exercise of independent

judgment and which are performed under the supervision of a clinical laboratory technologist, laboratory supervisor, or director of a

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 clinical

laboratory technologist or F clinical laboratory technician.

Signature: ______________________________________________________________________ Date _______ / _______ / _______

mo.

day

yr.

Print Name _____________________________________________________________________

F Check here if you are

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.

Clinical Laboratory Technologist/Technician Form 4A, Page 2 of 2, (Rev. 9/08)

Clinical Laboratory Technologist/technician Form 4a - Certification Of Experience Page 2

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