⇨

Blank California Lab 182 PDF Form

The California Lab 182 form is an application for certification as a phlebotomy technician, managed by the state’s Department of Health Services. This form is essential for individuals seeking to work in clinical laboratories, ensuring they meet the necessary qualifications and standards. To get started on your application, please fill out the form by clicking the button below.

Article Guide

The California Lab 182 form serves as a crucial step for individuals aspiring to become certified phlebotomy technicians in the state. This application is specifically designed for those seeking certification as either a Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), or Certified Phlebotomy Technician II (CPT II). Applicants must provide essential personal information, including their name, contact details, and social security number, as well as documentation proving their high school graduation or equivalent education. The form requires the submission of two passport-sized photos and a nonrefundable application fee of $54. It's important to note that applicants must also detail their educational background, including any phlebotomy training programs completed, and provide evidence of on-the-job experience in the field. Official transcripts and documentation of work experience must be sent directly to the appropriate state department. Additionally, the application includes a declaration statement that must be signed, affirming the truthfulness of the provided information. Understanding the requirements and ensuring that all necessary documentation is submitted accurately can significantly streamline the certification process.

Document Preview

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)
CLIA ID number:		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)

➤ PDF File

Form Specifications

Fact Name	Details
Governing Laws	This form is governed by 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.
Application Fee	A nonrefundable application fee of $54 must be attached to the application.
Required Photos	Two passport-sized photos are required to be submitted with the application.
Application Completeness	Applications must be fully completed. Incomplete applications will not be evaluated.
Certification Categories	Applicants must check one certification category: Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), or Certified Phlebotomy Technician II (CPT II).
Processing Time	Applicants should allow at least 60 days for processing, which begins upon receipt of a fully completed application and required documents.
Education Verification	Official documentation of high school graduation or equivalent must be sent directly to the Laboratory Field Services.
Criminal History Disclosure	Applicants must disclose any felony or misdemeanor convictions other than minor traffic violations.
Signature Requirement	Applicants must sign the application, declaring under penalty of perjury that all statements made are true and correct.

California Lab 182: Usage Guidelines

Filling out the California Lab 182 form is an important step in the process of obtaining phlebotomy technician certification. Following these steps will help ensure that your application is complete and properly submitted.

Gather Required Documents: Collect two passport-sized photos and prepare a nonrefundable payment of $54 via check, cashier’s check, or money order.
Complete Personal Information: Fill in your last name, first name, middle initial, mailing address, city, county, state, ZIP code, sex, date of birth, telephone number, and email address (if applicable).
Previous Names: If applicable, provide your maiden name or previous last name.
Social Security Number: Enter your United States social security number.
Certification History: Indicate if you have previously applied for certification or if you have been issued another California personnel certificate or license. Provide details if necessary.
Criminal History: Answer whether you have been convicted of any felonies or misdemeanors other than minor traffic violations. Attach a statement if applicable.
Education: Confirm that you have requested your transcripts to be sent directly to Laboratory Field Services.
Phlebotomy Training: Provide the name and address of the phlebotomy training program you attended, along with the total hours attended.
Practical Instruction: List the name and address of the facility where you received practical instruction, including the hours per week and estimated number of successful punctures.
On-the-Job Experience: Fill out details for up to three employers where you gained on-the-job experience in phlebotomy, including hours worked and successful punctures.
Certification Examination: Attach a copy of your phlebotomy certification examination results and provide the name of the certifying organization.
Signature: Sign and date the application in blue ink, declaring that all statements are true and correct.

Once the form is completed, it should be sent to the appropriate addresses listed in the instructions. Be sure to allow at least 60 days for processing, as this time frame is based on the receipt of your fully completed application and any required documents.

Your Questions, Answered

What is the California Lab 182 form used for?

The California Lab 182 form is an application for individuals seeking certification as a phlebotomy technician in California. This form is specifically designed for those who wish to apply for one of three certification categories: Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), or Certified Phlebotomy Technician II (CPT II). Completing this form is a crucial step in the process of becoming certified to perform phlebotomy in the state.

What are the requirements for submitting the California Lab 182 form?

To successfully submit the California Lab 182 form, applicants must meet several requirements. First, the form must be fully completed, as any incomplete application will not be evaluated. Additionally, applicants need to include a nonrefundable application fee of $54, along with two passport-sized photos. Official documentation proving high school graduation or its equivalent must also be sent directly to the designated address. Lastly, applicants must check only one certification category on the form.

How long does it take to process the California Lab 182 application?

Once the California Lab 182 application is submitted, applicants should allow at least 60 days for processing. This timeframe begins upon receipt of a fully completed application and all necessary official documents. It is important for applicants to ensure that all required materials are submitted correctly to avoid delays in the processing of their application.

What should I do if I have questions about the application process?

If you have questions regarding the application process for the California Lab 182 form, it is advisable to reach out to the appropriate department. The Laboratory Field Services (LFS) is the designated authority for handling inquiries related to phlebotomy technician certification. Contacting them directly can provide clarity on any specific concerns or uncertainties regarding the application requirements or submission process.

Common mistakes

Submitting an Incomplete Application: Failing to fill out every section of the form can lead to immediate rejection. Ensure all required fields are completed.
Incorrect Payment Method: Only checks, cashier’s checks, or money orders are accepted. Submitting cash will result in delays or rejection of your application.
Not Sending Official Transcripts: Applicants often forget to send their high school graduation documentation directly to the specified address, which is crucial for processing.
Choosing Multiple Certification Categories: It is essential to select only one certification category. Selecting more than one will cause confusion and delay your application.
Neglecting to Sign the Application: An unsigned application is invalid. Remember to sign in blue ink before submission to avoid rejection.

Documents used along the form

The California Lab 182 form is an essential document for individuals seeking certification as a phlebotomy technician in California. Along with this form, several other documents and forms may be required to ensure a complete application process. Below is a list of commonly used forms and documents that accompany the Lab 182 form, each serving a specific purpose in the application process.

Application Fee Payment: A nonrefundable payment of $54 must accompany the Lab 182 form. This can be made via check, cashier’s check, or money order, and it is crucial for processing the application.
Passport-Sized Photos: Two recent passport-sized photographs are required. These photos help in verifying the identity of the applicant and are attached to the application form.
High School Graduation Documentation: Official documentation proving high school graduation or its equivalent must be submitted. This can include transcripts or certificates from recognized educational institutions.
Phlebotomy Training Program Certificate: A certificate from a phlebotomy training program is necessary. This document verifies that the applicant has completed the required educational components of phlebotomy training.
On-the-Job Experience Documentation: A signed letter from a laboratory director or public health supervisor confirming the applicant's work experience in phlebotomy is essential. This letter should detail the applicant’s practical training hours and successful procedures performed.
Phlebotomy Certification Examination Results: A copy of the certificate indicating successful completion of a phlebotomy certification exam from a nationally recognized certifying organization is required. This demonstrates that the applicant has met the necessary competency standards.
Transcripts: Official transcripts from high school or post-secondary institutions must be sent directly to the Laboratory Field Services. These transcripts provide proof of educational qualifications and are a critical part of the application.
Supplemental Information Sheet: If applicable, an additional sheet may be required to provide further details regarding previous applications, certifications, or criminal history. This helps clarify the applicant's background for the reviewing agency.

Each of these documents plays a vital role in the certification process for phlebotomy technicians in California. Ensuring that all required forms and documents are completed and submitted accurately can significantly enhance the chances of a successful application. Taking the time to prepare these materials thoughtfully will contribute to a smoother and more efficient certification experience.

Similar forms

The California Lab 182 form serves as an application for phlebotomy technician certification. Several other documents share similarities with this form, particularly in their purpose and structure. Here are ten documents that resemble the California Lab 182 form:

California Lab 183: This form is used for the certification of medical laboratory technicians. Like Lab 182, it requires personal information, proof of education, and documentation of training.
California Lab 184: This document is for the certification of clinical laboratory scientists. It mirrors Lab 182 in needing an application fee, educational transcripts, and proof of clinical experience.
Certified Nursing Assistant (CNA) Application: Similar to Lab 182, this application requires personal details, proof of training, and a certification exam completion record.
Registered Nurse (RN) Application: This form collects personal information and educational background, just like Lab 182. It also mandates proof of clinical hours and examination results.
Medical Assistant Certification Application: This document requires an application fee and proof of training, akin to the requirements outlined in Lab 182.
Pharmacy Technician Certification Application: This application also requires personal information, proof of education, and documentation of training hours, similar to the Lab 182 format.
Occupational Therapy Assistant Application: Like Lab 182, this form requires applicants to submit personal information, educational transcripts, and clinical experience documentation.
Radiologic Technologist Certification Application: This document requests similar information, including training hours and proof of examination, paralleling the Lab 182 requirements.
Emergency Medical Technician (EMT) Application: The EMT application demands personal information, proof of training, and certification exam results, much like Lab 182.
Certified Health Education Specialist (CHES) Application: This form requires educational background and proof of training, similar to the structure and requirements of Lab 182.

These documents, while specific to their respective fields, share a common framework that includes personal details, educational proof, and evidence of practical experience, reflecting the structured nature of certification applications in healthcare professions.

Dos and Don'ts

When filling out the California Lab 182 form, it is essential to follow certain guidelines to ensure a smooth application process. Below are six key things to do and avoid.

Do complete the application fully. An incomplete form will not be evaluated.
Do send the application along with the required fee and photos to the specified address.
Do check only one certification category on the form to avoid confusion.
Do ensure that all official documents, including transcripts, are sent directly to the appropriate address.
Don't submit cash as payment; use a check, cashier’s check, or money order instead.
Don't forget to sign the application in blue ink to validate your submission.

By adhering to these guidelines, applicants can help facilitate the processing of their certification application.

Misconceptions

Many people have misconceptions about the California Lab 182 form, which is essential for those seeking certification as a phlebotomy technician. Here are eight common misunderstandings:

It’s just a simple form. Many believe that the Lab 182 is straightforward. However, it requires detailed information and documentation, including educational transcripts and proof of training.
Submitting an incomplete application is acceptable. Some applicants think they can submit the form without all necessary documents. In reality, an incomplete application will not be evaluated.
Only the application fee is necessary. While the $54 application fee is mandatory, applicants must also provide two passport-sized photos and official documentation of their education.
Any certification category can be checked. Applicants might assume they can select multiple certification categories. However, only one category should be checked to avoid confusion.
Processing time is quick. Many expect a fast turnaround. In truth, applicants should allow at least 60 days for processing, depending on the completeness of their submission.
High school equivalence is not a requirement. Some individuals believe they can bypass educational requirements. However, proof of high school graduation or equivalent is necessary for certification.
Previous convictions don’t matter. Some applicants think that past misdemeanors or felonies won’t affect their application. In fact, they must disclose this information, as it can impact eligibility.
Once submitted, no follow-up is needed. Many assume that after sending in the application, they can sit back and wait. However, it’s wise to follow up to ensure all documents were received and the application is being processed.

Understanding these misconceptions can help applicants navigate the certification process more effectively. Proper preparation and attention to detail are key to a successful application.

Key takeaways

Key Takeaways for the California Lab 182 Form:

Ensure the application is fully completed. An incomplete form will not be evaluated.
Submit the application along with a $54 application fee and two passport-sized photos.
Official transcripts and documentation must be sent directly to the designated address for processing.
Only select one certification category from the options provided to avoid delays in processing.