List below all personnel with responsibilities for testing in the last two years.
Not listed: do not list personnel that only perform specimen processing, clerical functions, waived or no testing.
Positions: for moderate complexity testing, list the positions of LD, CC, TC and TP. For high complexity testing, list the positions of LD, CC, TS, GS and TP.
Separate line: use a separate line for personnel holding more than one CLIA position.
Laboratory director: only one person may be listed as the laboratory director.
Qualification: indicate each individual's highest level of qualification: use (M) for moderate and (H) for high complexity.
| Question | Answer |
|---|---|
| Form Name | Form CMS-209 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 165 |
| Avg. time to fill out | 28 min |
| Edition | 09/2025 |
| Issuing agency | Centers for Medicare & Medicaid Services |
| Who signs | The laboratory director |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | CMS-209, CMS 209, CMS209, Form 209, Laboratory Personnel Report (CLIA) |
| Official source | Form CMS-209 (Rev 09/2025), Centers for Medicare & Medicaid Services |
Laboratory Personnel CMS-209 Form isn’t the one you’re looking for?