The California Lab 182 form is a crucial application for individuals seeking certification as phlebotomy technicians in the state. This form, governed by various California regulations, requires applicants to provide personal information, educational background, and proof of training. Completing this form accurately is essential for a smooth certification process, so be sure to fill it out carefully by clicking the button below.
The California Lab 182 form is an essential document for individuals seeking certification as a phlebotomy technician in California. This form is part of the application process overseen by the Department of Health Services and is designed to ensure that applicants meet specific educational and training requirements. To complete the application, individuals must provide a variety of personal information, including their name, contact details, and social security number. The form also requires documentation of high school graduation or an equivalent qualification, along with proof of completion of a phlebotomy training program. Applicants must choose one certification category, such as Limited Phlebotomy Technician or Certified Phlebotomy Technician I or II. Additionally, the application process includes submitting a nonrefundable fee and two passport-sized photos. It is important to note that any incomplete applications will not be evaluated, which emphasizes the need for thoroughness. After submission, applicants should expect a processing time of at least 60 days, during which their documents will be reviewed by Laboratory Field Services. This form plays a critical role in maintaining the standards of phlebotomy practice in California, ensuring that certified technicians are well-prepared to perform their duties safely and effectively.
State of California—Health and Human Services Agency
California Department of Public Health
OWNER’S ATTESTATION
I attest that effective
, I am the laboratory owner, or a co-owner of:
(date)
clinical laboratory, located at
(name of laboratory)
CLIA ID number:
(street address)
State ID number (if known):
As the owner or co-owner, I understand I am legally responsible for the operation of the laboratory under both CLIA and State law. I understand that as an owner of this laboratory, I, along with the director, must ensure the accuracy and reliability of all testing performed and that the laboratory meets all applicable CLIA and state requirements.
I understand that I will be held jointly and severally responsible with the laboratory director(s) for the maintenance and conduct of the laboratory and all employees therein or for any violations of law by this clinical laboratory (Business and Professions Code (BPC) section 1265(b)). If deficient or unlawful practices are found that occurred while I was serving as laboratory owner or co-owner, which the laboratory fails or is unable to correct, and which results in the revocation of the laboratory’s CLIA certificate or state license or registration, I understand that pursuant to Title 42 of the United States Code (USC), section 263(a)(i) (3), 42 CFR 493.1840(a)(8), and BPC section 1324, I would be prohibited from owning, operating, or directing another clinical laboratory for a period of at least two years from the date of revocation. Such action may also be grounds for referral to the Medical Board of California or other licensing board for appropriate action.
I understand that any reasons listed in BPC section 1320, including any false statement or representation of fact in obtaining or retaining CLIA certification or state licensure or registration may be grounds for revocation of the laboratory’s CLIA certificate under 42 CFR 493.1840(a)(1), and state license or registration under BPC section 1320 and may subject me to criminal or civil sanctions.
I understand that I will be responsible, along with the laboratory director(s), to notify the Department of Public Health in writing of any changes in the laboratory ownership, directorship, name or location within thirty days of the change, and that failure to provide such notification will result in automatic revocation of the state license or registration (BPC section 1265(g)), and sanctions against the CLIA certificate (42 CFR 493.39(b), 493.45(b)(2), 493.51(a), 493.53(a), 493.57(a)(2), and 493.63(a)).
I understand that I will continue to be held responsible as a laboratory owner of this laboratory until the day that the California Department of Public Health receives a signed statement from me notifying the Department of my resignation or termination.
I affirm under penalty of perjury, that all information I have given in this document is true. This statement must be signed by the owner or a person legally authorized by the owner.
Owner or Authorize Representative’s signature
Date
Print or type name and title
Owner's contact telephone number
Owner’s address
LAB 182 (12/17)
Completing the California Lab 182 form is essential for those seeking certification as a phlebotomy technician. This process requires careful attention to detail and adherence to specific instructions. After submitting the form, applicants should anticipate a processing period of at least 60 days, contingent upon the receipt of all necessary documentation.
What is the California Lab 182 form?
The California Lab 182 form is an application for certification as a Phlebotomy Technician in the state of California. It is managed by the Department of Health Services and is essential for individuals seeking to work in this field. The form requires applicants to provide personal information, educational background, and proof of training in phlebotomy.
What are the requirements to complete the Lab 182 form?
To successfully complete the Lab 182 form, applicants must provide a full set of personal details, including their name, address, date of birth, and social security number. Additionally, they must include documentation of high school graduation or its equivalent, proof of phlebotomy training, and two passport-sized photos. A nonrefundable application fee of $54 is also required.
How should I submit the Lab 182 form?
The completed Lab 182 form, along with the application fee and required documents, should be mailed to CPS Human Resource Services at the specified address. It is important to ensure that all items are included, as an incomplete application will not be evaluated.
What certification categories can I choose from on the Lab 182 form?
Applicants must select one certification category from the options provided on the form. The choices include Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), and Certified Phlebotomy Technician II (CPT II). Each category has specific requirements and levels of training, so it’s crucial to choose the one that aligns with your qualifications.
How long does it take to process the Lab 182 application?
After submitting a fully completed application, applicants should allow at least 60 days for processing. This timeline is contingent upon the receipt of all necessary documentation and the completeness of the application. Applicants can check the status of their application if they have concerns about the processing time.
What happens if I have a criminal record?
If you have been convicted of any felonies or misdemeanors, other than minor traffic violations, you must disclose this information on the application. It is important to attach a statement providing details about the conviction. The Department will evaluate this information as part of the application process.
Is it necessary to send official transcripts?
Yes, applicants are required to send official transcripts directly from their educational institution to the Laboratory Field Services. This step is crucial for verifying educational qualifications and ensuring that all requirements for certification are met.
What should I do if I have previously applied for certification?
If you have applied for this or a similar certification in the past, you must indicate this on the application form. Providing the name used and the date of the previous application helps the Department track your certification history and ensures that all records are up to date.
When filling out the California Lab 182 form, applicants often make mistakes that can delay the processing of their certification. One common error is submitting an incomplete application. The instructions clearly state that the application must be fully completed for it to be evaluated. Missing information, such as the applicant's last name or date of birth, can result in the application being rejected. It is essential to double-check all sections to ensure that every required field is filled out correctly.
Another frequent mistake involves the payment method. The application requires a nonrefundable fee of $54, which must be paid via check, cashier’s check, or money order. Some applicants mistakenly send cash, which is not accepted. This oversight can lead to delays as the application will not be processed until the correct payment method is received. Therefore, it is crucial to follow the payment instructions precisely to avoid any setbacks.
Additionally, applicants sometimes fail to send the official documentation of their high school graduation or equivalent directly to the appropriate address. The instructions specify that this documentation must be sent to the Laboratory Field Services in Richmond, CA. If this step is overlooked, it can result in further delays in processing the application. Ensuring that all required documents are sent to the correct location is vital for a smooth application process.
Lastly, many applicants neglect to check the certification category they are applying for. The form requires individuals to select only one certification category, such as Limited Phlebotomy Technician or Certified Phlebotomy Technician I. Failing to make a selection or incorrectly marking multiple categories can lead to confusion and potential rejection of the application. It is important to carefully read the instructions and make the appropriate choice to avoid complications.
When applying for certification as a phlebotomy technician in California, several additional forms and documents may be required alongside the California Lab 182 form. Each of these documents serves a specific purpose in ensuring that applicants meet the necessary qualifications and standards. Below is a list of commonly used forms and documents that are often submitted with the Lab 182.
Submitting these documents along with the California Lab 182 form ensures that the application process runs smoothly. Each piece of information plays a critical role in evaluating an applicant's qualifications and readiness for a career in phlebotomy. Proper preparation can significantly enhance the chances of a successful application.
Completing the California Lab 182 form is a crucial step in your journey to becoming a certified phlebotomy technician. To ensure a smooth application process, here are some essential dos and don'ts to keep in mind:
By following these guidelines, you can navigate the application process with confidence and clarity. Good luck on your path to certification!
Understanding the California Lab 182 form is essential for anyone pursuing a career as a phlebotomy technician. However, several misconceptions often arise regarding this application process. Here are nine common misconceptions explained:
The application requires a nonrefundable fee of $54. Submitting the form without this payment will result in rejection.
Applications must be fully completed. An incomplete application will not be evaluated, leading to delays.
Only official documentation of high school graduation or equivalent is accepted. This must be sent directly to the specified address.
Applicants must check only one certification category on the form. This helps streamline the evaluation process.
Applicants should allow at least 60 days for processing, as this time frame is contingent upon the receipt of all required documents.
Applicants must disclose any felony or misdemeanor convictions. Failure to do so can result in disqualification.
Transcripts must be sent directly from the educational institution to the Laboratory Field Services. Self-submissions will not be accepted.
Applicants must attach a copy of the certification examination results from an approved national certifying organization.
The applicant's signature must be in blue ink. This is a specific requirement for the application to be valid.
By clarifying these misconceptions, applicants can better navigate the Lab 182 form process and ensure their applications are complete and accurate.
Filling out the California Lab 182 form is a crucial step for anyone aspiring to become a certified phlebotomy technician in California. Here are some key takeaways to keep in mind:
By keeping these points in mind, you can navigate the application process with greater ease and confidence. Make sure to double-check your application before submission to avoid any delays in your certification journey.