Clinical Laboratory Technologist/technician Form 4c - Certification Of Expierence And Competence 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 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”
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
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: ______________________
I further attest that such experience was performed competently.
See the definitions of practice for clinical laboratory technologists and clinical laboratory technicians on page 1.
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 (check
one): F clinical laboratory technologist or F clinical laboratory technician.
Signature: ______________________________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Print Name _____________________________________________________________________
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 4C, Page 2 of 2, (Rev. 9/08)
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