Clinical Laboratory Technologist/technician Form 4c - Certification Of Expierence And Competence
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1
21.
2.
3.
4.
The University of the State of New York
Clinical Laboratory
THE STATE EDUCATION DEPARTMENT
Technologist/Technician
Office of the Professions
Division of Professional Licensing Services
Form 4C
Certification of Experience and Competence
(For Applicants using Grandparenting Methods 1A and 6A Only)
(Applications using these methods will only be accepted if submitted by September 1, 2013.)
Applicant Instructions
Complete Section I and forward this entire form to the Clinical Laboratory Director to complete Section II. This form may be photocopied, but
both pages of all forms must be returned directly by the Clinical Laboratory Director and must bear an original signature of the Clinical
Laboratory Director.
Section I: Applicant Information
1
2
Social Security Number
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Name As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Name of Clinical Laboratory Director I am asking to complete this form: ___________________________________________________
Check one:
F I practiced as a clinical laboratory technologist for a minimum of six months (at least 720 clock hours) and I am applying for
licensure under grandparenting method 6A (only report hours from December 31, 2004 through December 31, 2007).
"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.
F I practiced as a certified clinical laboratory technician for a minimum of six months (at least 720 clock hours) and I am applying
for licensure under grandparenting method 1A (only report hours from December 31, 2004 through December 31, 2007).
"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.
Duration of supervised experience:
Date beginning: _______ / _______ /
_______
Date ending: _______ /
_______ /
_______
mo.
day
yr.
mo.
day
yr.
Total clock hours practicing: __________________
6
I request and give my permission to the individual listed in item 5 above to complete Section II of this form and mail it to the New York
State Education Department at the address at the end of this form, and to release any other information requested by the State
Education Department in connection with my application for licensure. I also declare and affirm that the statements made in this
application, including accompanying documents, are true, complete and correct. I understand that any false or misleading information in,
or in connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.
Applicant's signature: _____________________________________________________________ Date:_______ / _______ / _______
mo.
day
yr.
Clinical Laboratory Technologist/Technician Form 4C, Page 1 of 2, (Rev. 9/08)
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