Lab 177 Form PDF Details

In the realm of health and human services in California, the importance of continuous professional education cannot be overstated, especially for those in the medical and clinical laboratory field. To this end, the State of California, through its Health and Human Services Agency and the California Department of Public Health, mandates the renewal of personnel clinical laboratory licenses or certificates contingent upon the fulfillment of specific continuing education (CE) requirements. This process is formalized through the submission of the Lab 177 form, a crucial document that outlines the CE activities of the applicant. At the heart of the renewal process, individuals must detail their engagement in approved continuing education programs, including program titles, course numbers, the accrediting agency, and the hours earned, ensuring their professional knowledge remains current and comprehensive. The form serves as a testament to the dedication of clinical laboratory personnel towards maintaining the highest standards of competency in their field. Moreover, it highlights the procedural steps for renewal, including the submission timeline, fee schedules, and the necessity to retain CE documentation for audit purposes. This protocol solidifies the commitment of the California Department of Public Health to uphold quality and reliability within clinical laboratory services, ensuring that personnel are well-equipped with the latest knowledge and skills in their respective domains.

Form NameLab 177 Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameslab 101 form, lfs form lab 101, lab 177, lab 101

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State of California—Health and Human Services Agency

California Department of Public Health



Each person licensed under Division 2, Chapter 3 of the California Business and Professions Code (BPC), commencing with Section 1200, whose license or certificate is in active status must complete the required continuing education hours.

At the time of renewal, you must provide the Department with the date of issue on certificate, California approved accrediting agency number (AA number) and name, program title, course number, and number of contact hours received for each continuing education program you have successfully completed. Please complete and return the Continuing Education Activity Summary (on the back of this page).

NOTE: Submit the renewal application with the CE Activity Summary and renewal fee. The renewal fee can be found on

the following website:

Title 17 of the California Code of Regulations, section 1031.5, requires a license or certificate to be renewed by filing a renewal application at least 60 days prior to the end of the license or certificate period.

Please note: LFS does not accept applications, renewals, or inquiries in person at the Richmond office. Applications must be sent by mail. Inquiries can be submitted by email or by telephone (510-620-3800). Applications are processed in the order in which they are received.

CE requirements (California Business and Professions Code section 1260)

Directors, Cytotechnologists, Clinical Laboratory Scientists, and Medical Laboratory Technicians: O 24 CE hours per 2-year renewal cycle


O6 CE hours per 2-year renewal cycle

You must retain for a minimum of four years the continuing education documents received from providers approved under the California Code of Regulations, Title 17, section 1038.4. Do not forward such documents to the department unless you are instructed to do so.

A number of renewal applications will be audited by the department each year. A notice will be sent by mail to those who are selected.

Regulations require that you notify this office by email WITHIN 30 DAYS of any change of name or address. Send notification to Laboratory Field Services at Please put “Change of Address” in the subject line.


Name: ___________________________________________________________________________________________

Daytime telephone number: _______________________ Home telephone number: _____________________________

E-mail address (if available): _________________________________________________________________________

Laboratory Field Services

(510)620-3800 (510) 620-3692 FAX Internet Address:

LAB 177 A (revised 3/16)

Page 1 of 2

State of California – Health and Human Services Agency

California Department of Public Health


Laboratory Field Services



Return to:

California Department of Public Health

Please write your license or certificate number on your check.


Accounting Section / Cashiering Unit





MS 1601 P. O. Box 997376






Sacramento, CA 95899-7376















License/Certificate Number


Phone – Daytime

Phone – Alternate







Mailing Address (number, street)





ZIP Code







Email address (if available)









Is this a change of name or address since the last renewal?




Since the last renewal have you been convicted of any felonies or misdemeanors other than minor traffic violations?

Yes No

If yes, provide a statement of explanation on a supplementary sheet.


If you are randomly selected for audit, the Department will request you to send copies of your certificates or transcripts.

You MUST complete the question above and sign on the signature line below to certify the authenticity of your CE courses.


List all required information found on the CE certificate issued by the California Continuing Education Accrediting Agency after successfully completing the course. Record only the CE units earned since the last renewal period. (Use a supplementary sheet if necessary.)

Date of Issue on

Calif. AA

CE Certificate




Program Title

Accrediting Agency Name

Course Number

CE Units


List all successfully completed accredited college or university courses relevant to clinical laboratory science scope of practice since the last renewal period. (Use a supplementary sheet if necessary.)

College or University

Course Number and Title

Semester /

Quarter Units

Course Dates

from / to

I attest that I have taken the current courses listed above and have certificates in my possession to verify successful completion of the continuing education courses listed in Section 1 or an official transcript for the courses from an accredited college or university listed in Section 2. I understand that I am responsible for maintaining these legal documents for four years.

Warning: Failure to provide complete information may result in delay in processing your license/certification renewal.

Signature: __________________________________________________

Date: ______________________________



Laboratory Field Services

(510)620-3800 (510) 620-3692 FAX Internet Address:

LAB 177 B (revised 3/16)

Page 2 of 2

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Provide the demanded data in the area PLEASE PROVIDE THE FOLLOWING, Name, Daytime telephone number Home, Email address if available, FAX LFSRenewalscdphcagov, Laboratory Field Services, LAB A revised, and Page of.

step 2 to entering details in lab 177

The application will request for additional info to effortlessly complete the segment Name, LicenseCertificate Number, Phone Daytime, Phone Alternate, Mailing Address number street, City, State, ZIP Code, Email address if available, Is this a change of name or, Yes, Since the last renewal have you, DO NOT SEND ORIGINAL OR COPIES OF, You MUST complete the question, and Section ACCREDITING AGENCY.

Finishing lab 177 part 3

Through box List all successfully completed, Section COLLEGE OR UNIVERSITY, College or University, Course Number and Title, Semester Quarter Units, Course Dates from to, I attest that I have taken the, Warning Failure to provide, Signature Date, Laboratory Field Services FAX, LAB B revised, and Page of, identify the rights and obligations.

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