California Form LAB 182 PDF Details

Embarking on a career as a Phlebotomy Technician in California requires following a well-defined path set by the state's Health and Human Services Agency, with the California Lab 182 form playing a crucial role in this journey. This form acts as a gateway for aspiring technicians to apply for their certification, adhering to guidelines embedded in the state's regulations and statutes. It's not just about filling out personal information; applicants must also navigate through requirements such as attaching a $54 application fee, two passport-sized photos, and providing proof of high school graduation or its equivalent. The form prompts candidates to choose among three certification categories: Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), and Certified Phlebotomy Technician II (CPT II), each with its own set of prerequisites and training hours. Moreover, it demands detailed educational and practical training backgrounds, including any on-the-job experience in phlebotomy. The process is comprehensive, requiring submissions to be sent to specific addresses, with a clear warning that incomplete applications will not be evaluated. Through detailed sections that must be filled meticulously, the form ensures that applicants are well-versed in both theoretical and practical aspects of phlebotomy, aiming to maintain high standards within California's healthcare services.

QuestionAnswer
Form NameCalifornia Form LAB 182
Form Length1 pages
Fillable?Yes
Fillable fields10
Avg. time to fill out2 min 15 sec
Other namesapplication fcctifresnocitycollegeedu form

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State of California—Health and Human Services Agency

Department of Health Services

PHLEBOTOMY TECHNICIAN CERTIFICATION APPLICATION

Refer to California Business and Professions Code, Sections 1242.5, 1246, and 1282.2; California Code of Regulations, Title 17, Sections 1029.31–1029.35, 1031.4, 1031.5, and 1034; and Health and Safety Code, Section 120580.

Instructions: Attach $54 application fee and two passport-sized photos.

1.Please fully complete this application. An incomplete application will not be evaluated.

2.Send the fully completed application, nonrefundable check, cashier’s check, or money order (no cash please) payable to:

CPS Human Resource Services

Attention: CLS Program

241 Lathrop Way

Sacramento, CA 95815

3.Official documentation of high school graduation or equivalent, and all required documentation must be sent directly to the address below.

DHS—Laboratory Field Services (LFS) 850 Marina Bay Parkway, Bldg. P, 1st flr. Richmond, CA 94804-6403

4. Check ONE certification category only.

Limited Phlebotomy Technician (LPT) Certified Phlebotomy Technician I (CPT I) Certified Phlebotomy Technician II (CPT II)

FOR DEPARTMENTAL USE ONLY

Limited

CPT I

CPT II

Approve

Reject

 

Date:__________________

By: _________

Reason: _____________________________

Fee paid

Photos attached

OTJE: Months:________ Years:________

Hours of training completed:

Didactic:_________ Practical: __________

50 Vein

10 Skin

20 Artery

Passed certifying exam:

Yes

No

State certificate number:

____________________________________

Date issued:__________________________

LFS file ID number: ____________________

PLEASE NOTE: Official transcripts must be sent directly to the above address. Please allow at least 60 days for processing the application. The processing time is based upon receipt of the fully completed application and official documents as required by Laboratory Field Services.

1.

Last name

 

 

 

First name

 

 

 

 

 

Middle initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address (number and street or P.O. Box number)

 

City

 

 

County

 

State

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

2.

Sex

 

3. Date of birth (month/day/year)

4.

Telephone number

 

5.

E-mail address (if applicable)

 

Female

Male

 

 

 

 

(

)

 

 

 

 

 

6.

Maiden name or previous last name (if applicable)

 

7.

United States social security number

 

 

 

 

 

 

 

 

 

 

___ ___ ___ – ___ ___ – ___ ___ ___ ___

8.

Have you previously applied for this or similar certification?

If yes, name used and date

 

 

 

 

 

Yes

No

9.Have you been issued another California personnel certificate or license? (Attach a separate sheet if needed.)

Yes

No

Type of certification/licensure

Certificate/license number

10.Have you been convicted of any felonies or misdemeanors other than minor traffic violations? If yes, attach a statement giving details

Yes

No

Comments

11.Education Transcripts

I have requested that my transcript be sent directly from the registrar’s office to Laboratory Field Services (see instructions, item 2 above for mailing address).

Date requested

Comments:

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LAB 182 (9/05)

12.Education

Name of High School, College, or University

City and State OR Country

Semester

Units

From To

Month/Year Month/Year

High School

Graduation Equivalence

Date Date*

13.Didactic Instruction in PhlebotomyAttach a copy of the certificate issued by the phlebotomy training program.

Name of Phlebotomy Training Program and Address

City and State

County

From

Month/Year

To

Month/Year

Total Hours

Attended

Please attach a separate sheet if more space is needed.

14.Practical Instruction in PhlebotomyAttach a copy of certificate if different than certificate from item 13.

Name of Hospital, Reference, Clinics, or Physician Office Laboratory, and Address

City and State

County

Hours

Per From To

Week Month/Year Month/Year

Estimated Number of Successful Punctures

Skin

Vein

Artery

 

 

 

Please attach a separate sheet if more space is needed.

15.a. On-the-Job Experience (OTJE) in Phlebotomy

Name of employer

Address (number, street)

Hours

Per From To

Week Month/Year Month/Year

Estimated Number of Successful Punctures

Skin

Vein

Artery

City

State

ZIP code

15.b. On-the-Job Experience (OTJE) in Phlebotomy

Name of employer

Address (number, street)

Hours

Per From To

Week Month/Year Month/Year

Estimated Number of Successful Punctures

Skin

Vein

Artery

City

State

ZIP code

15.c. On-the-Job Experience (OTJE) in Phlebotomy

Name of employer

Address (number, street)

Hours

Per From To

Week Month/Year Month/Year

Estimated Number of Successful Punctures

Skin

Vein

Artery

City

State

ZIP code

Please attach a separate sheet if more space is needed.

*High School Equivalence: Equivalence to completion of the 12th grade may be demonstrated in any one of the following ways: (1) pass the General Educational Development (GED) test; (2) pass the High School Proficiency Examination (HSPE); (3) evaluation by the American Association of Collegiate Registrars and Admissions Officers (AACRAO) for Secondary Education indicating education equivalent to graduation from high school.

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LAB 182 (9/05)

16. Yes, I have requested that the laboratory director/public health supervisor send signed documentation of my work experience in phlebotomy directly to Laboratory Field Services (for mailing address—see page 1, instructions, item 2).

Date requested

Comments

17.Phlebotomy Certification Examination

Attach a copy of the certificate indicating that you successfully passed a phlebotomy certification examination offered by a national certifying organization approved by the Department of Health Services.

Name of certifying organization

Comments

Date of examination

Effective date

18.Signature of Applicant

I declare under penalty of perjury that all statements made in this application are true and correct, and I agree and understand that any misstatements of material facts herein will cause forfeiture on my part of all rights under the laws of California relating to clinical laboratories.

Applicant’s signature (Please use blue ink.)

Date

The Family Code, Section 17520, requires Laboratory Field Services to collect social security numbers from all applicants. All items are mandatory and the information requested must be furnished. The information is used to properly identify an applicant and to determine an individual’s eligibility for certification as authorized under the provisions of the Business and Professions Code, Division 2, Chapter 3, and the California Code of Regulations, Title 17, Chapter 2. Failure to provide this information will preclude acceptance of your application.

DO NOT WRITE IN THIS SECTION.

Page 3 of 3

LAB 182 (9/05)

How to Edit California Form LAB 182 Online for Free

Any time you would like to fill out California Form Lab 182, you won't need to download any applications - just make use of our PDF tool. To have our editor on the forefront of convenience, we strive to put into practice user-oriented features and enhancements on a regular basis. We're at all times looking for feedback - assist us with revolutionizing how we work with PDF docs. This is what you would want to do to start:

Step 1: Access the PDF file in our tool by hitting the "Get Form Button" above on this page.

Step 2: As soon as you launch the file editor, you'll notice the form made ready to be completed. Aside from filling in different blanks, you can also perform some other things with the file, including adding any text, editing the original text, adding illustrations or photos, affixing your signature to the document, and much more.

It is actually an easy task to complete the form with this helpful tutorial! Here's what you should do:

1. To begin with, once completing the California Form Lab 182, start with the part that contains the subsequent fields:

California Form Lab 182 writing process described (step 1)

2. The third stage is to submit these blank fields: Mailing address number and street, City, County, State, ZIP code, Sex, Date of birth monthdayyear , Email address if applicable, Female, Male, Maiden name or previous last name, United States social security, Have you previously applied for, If yes name used and date, and Yes.

Stage # 2 of filling out California Form Lab 182

3. This next stage is straightforward - complete all of the empty fields in Name of High School College or, City and State OR Country, Units, MonthYear, MonthYear, Date, Semester, From, Graduation, Equivalence, Date, Didactic Instruction in, Name of Phlebotomy Training, City and State, and County to finish this segment.

California Form Lab 182 conclusion process shown (part 3)

4. The following subsection needs your attention in the following places: Name of employer, Address number street, City, State, ZIP code, b OntheJob Experience OTJE in, Name of employer, Address number street, City, c OntheJob Experience OTJE in, Name of employer, Address number street, City, State, and ZIP code. Make sure you type in all of the needed details to go onward.

Name of employer, Name of employer, and City of California Form Lab 182

5. The form needs to be finalized by filling in this section. Here one can find an extensive list of blanks that need to be completed with appropriate information to allow your document submission to be faultless: Yes I have requested that the, phlebotomy directly to Laboratory, Date requested, Comments, Phlebotomy Certification, Attach a copy of the certificate, Name of certifying organization, Date of examination, Effective date, Comments, Signature of Applicant, I declare under penalty of perjury, Applicants signature Please use, and Date.

Tips on how to fill in California Form Lab 182 portion 5

Be really mindful while filling in Applicants signature Please use and Date of examination, because this is the part in which most people make mistakes.

Step 3: Prior to obtaining the next stage, ensure that blanks are filled out the right way. The moment you confirm that it's correct, click “Done." Right after starting a7-day free trial account here, it will be possible to download California Form Lab 182 or send it via email directly. The PDF file will also be at your disposal in your personal account menu with all of your modifications. FormsPal is invested in the privacy of all our users; we ensure that all personal information used in our system continues to be secure.