Outline
The California Lab 182 form is an essential document for individuals seeking certification as phlebotomy technicians in the state. This form serves as the official application for the certification process, which is governed by specific regulations outlined in the California Business and Professions Code and the California Code of Regulations. To successfully complete the application, candidates must provide personal information, including their name, contact details, and social security number. Additionally, applicants are required to submit proof of high school graduation or equivalent education, along with documentation of their phlebotomy training and practical experience. A nonrefundable application fee of $54, along with two passport-sized photos, is also necessary for processing. The form allows candidates to select their desired certification category, whether it be Limited Phlebotomy Technician, Certified Phlebotomy Technician I, or Certified Phlebotomy Technician II. It is crucial to ensure that all sections of the form are thoroughly completed, as any omissions may delay or hinder the evaluation process. Once submitted, applicants should anticipate a processing time of at least 60 days, contingent upon the receipt of all required documentation. Understanding the requirements and carefully following the instructions on the California Lab 182 form can significantly streamline the path to achieving certification.
Sample - California Lab 182 Form
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California Department of Public Health |
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OWNER’S ATTESTATION |
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I attest that effective |
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, I am the laboratory owner, or a |
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(date) |
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clinical laboratory, located at |
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(name of laboratory) |
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CLIA ID number: |
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(street address) |
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State ID number (if known): |
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As the owner or
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
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)
Form Information
| Fact Name | Details |
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| Governing Laws | The California Lab 182 form is governed by the 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 | Applicants must attach a nonrefundable application fee of $54 along with two passport-sized photos when submitting the form. |
| Submission Requirements | The application must be fully completed. Incomplete applications will not be evaluated. Additionally, official documentation of high school graduation or its equivalent is required. |
| Certification Categories | Applicants must select only one certification category from Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), or Certified Phlebotomy Technician II (CPT II). |
| Processing Time | Once the application and all required documents are received, applicants should allow at least 60 days for processing. |
Detailed Guide for Filling Out California Lab 182
Completing the California Lab 182 form requires careful attention to detail. Once the form is filled out and submitted, it will undergo a review process. This step is crucial for ensuring that all necessary information is accurately provided, allowing for a smooth certification journey.
- Begin by entering your last name, first name, and middle initial in the designated fields.
- Fill in your mailing address, including the number and street or P.O. Box number, city, county, state, and ZIP code.
- Indicate your sex by checking the appropriate box.
- Provide your date of birth in the format of month/day/year.
- Enter your telephone number.
- If applicable, include your e-mail address.
- List your maiden name or previous last name, if applicable.
- Fill in your United States social security number.
- Answer whether you have previously applied for this or a similar certification. If yes, provide the name used and date.
- Indicate if you have been issued another California personnel certificate or license, and provide details if applicable.
- Answer whether you have been convicted of any felonies or misdemeanors other than minor traffic violations. Attach a statement if yes.
- Confirm that you have requested your education transcripts to be sent directly to Laboratory Field Services.
- List the name of your high school, college, or university, along with the city, state, or country, and the dates attended.
- Provide details about your didactic instruction in phlebotomy, including the name of the training program, total hours attended, and attach the required certificate.
- Detail your practical instruction in phlebotomy, including the name of the facility, total hours, and estimated number of successful punctures.
- For on-the-job experience, provide information for up to three employers, including address, hours worked, and estimated successful punctures.
- Confirm that you have requested the laboratory director or public health supervisor to send documentation of your work experience directly to Laboratory Field Services.
- Attach a copy of your phlebotomy certification examination certificate.
- Sign and date the application, ensuring you use blue ink.
After completing the form, remember to attach the required $54 application fee and two passport-sized photos. Ensure that all documents are sent to the correct addresses as specified in the instructions. Patience is key, as processing may take up to 60 days once your application is received.
Obtain Answers on California Lab 182
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What is the California Lab 182 form?
The California Lab 182 form is an application for certification as a phlebotomy technician in California. It is used by individuals seeking to obtain certification as a Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), or Certified Phlebotomy Technician II (CPT II).
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What are the requirements for submitting the Lab 182 form?
To submit the Lab 182 form, applicants must:
- Complete the application fully, ensuring no sections are left blank.
- Include a nonrefundable application fee of $54.
- Attach two passport-sized photos.
- Send official documentation of high school graduation or equivalent directly to the specified address.
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Where should I send my completed application?
Your completed application should be mailed to:
CPS Human Resource Services
Attention: CLS Program
241 Lathrop Way
Sacramento, CA 95815 -
How long does it take to process the application?
Processing the application typically takes at least 60 days. This timeline starts from the date the fully completed application and all required documents are received by Laboratory Field Services.
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What happens if I submit an incomplete application?
If the application is incomplete, it will not be evaluated. Ensure that all sections are filled out and all required documents are attached to avoid delays.
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What types of phlebotomy certification can I apply for?
You can apply for one of the following certification categories:
- Limited Phlebotomy Technician (LPT)
- Certified Phlebotomy Technician I (CPT I)
- Certified Phlebotomy Technician II (CPT II)
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What documentation is required for education verification?
Applicants must submit official transcripts showing completion of high school or equivalent education. Additionally, documentation proving completion of a phlebotomy training program must be included.
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What 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 on the application. A statement detailing the circumstances should be attached.
Common mistakes
Filling out the California Lab 182 form can be a straightforward process, but many applicants make critical mistakes that can delay their certification. One common error is leaving the application incomplete. An incomplete application will not be evaluated, which means you risk wasting time and resources. Ensure every section is filled out completely before submission.
Another frequent mistake is failing to attach the required documentation. Applicants often overlook the need for official transcripts and certificates. Without these documents, the application cannot be processed. It’s essential to double-check that all necessary materials are included.
Many individuals also neglect to send the application fee correctly. The form specifies that payment should be made via a nonrefundable check, cashier’s check, or money order. Sending cash or forgetting the fee altogether can lead to immediate rejection of your application.
Choosing the correct certification category is crucial. Some applicants mistakenly check more than one category, which can confuse the processing team. You must select only one certification category: Limited Phlebotomy Technician, Certified Phlebotomy Technician I, or Certified Phlebotomy Technician II.
Inaccuracies in personal information are another common issue. Applicants sometimes provide incorrect social security numbers or misspell their names. Such errors can cause significant delays in processing your application. Verify all personal details before submission to avoid complications.
Not providing a detailed account of any criminal history is also problematic. If you have been convicted of any felonies or misdemeanors, you must attach a statement detailing the circumstances. Failing to disclose this information can lead to serious consequences, including denial of your application.
Another mistake is underestimating the time needed for processing. Many applicants expect quick results but fail to account for the stated 60-day processing period. Patience is essential, as rushing can lead to further mistakes or incomplete submissions.
Additionally, applicants often forget to sign the application. The form requires a signature in blue ink, and without it, your application cannot be processed. This simple oversight can be easily avoided by making it a final step before submission.
Finally, some individuals do not follow up on their application status. After submitting the Lab 182 form, it’s advisable to check in with the appropriate department to ensure everything is in order. Being proactive can help address any issues that may arise during processing.
Documents used along the form
The California Lab 182 form is a critical document for individuals seeking certification as phlebotomy technicians in California. However, several other forms and documents are often required or recommended to complete the certification process. Below is a list of these documents, each serving a specific purpose in the application journey.
- Official Transcripts: These documents provide proof of educational qualifications, including high school graduation or equivalent. They must be sent directly from the educational institution to the Laboratory Field Services.
- Phlebotomy Training Certificate: This certificate confirms that the applicant has completed an accredited phlebotomy training program. It is essential to demonstrate the required educational background in the field.
- On-the-Job Experience Documentation: Employers must provide signed letters detailing the applicant's work experience in phlebotomy. This document verifies the practical training received in a professional setting.
- Phlebotomy Certification Examination Results: Applicants must submit a copy of the certificate indicating successful completion of a national phlebotomy certification exam. This verifies that the individual has met the necessary testing standards.
- Application Fee Payment: A nonrefundable fee, typically in the form of a check or money order, must accompany the application. This fee is essential for processing the application.
- Passport-Sized Photos: Two recent passport-sized photos are required for identification purposes. These images must meet specific guidelines set by the certifying body.
- Social Security Number Verification: Applicants must provide their social security number as part of the application. This information is used to verify identity and eligibility for certification.
- Criminal Background Disclosure: If applicable, applicants must disclose any felony or misdemeanor convictions. A separate statement detailing this information may be required.
- Request for Transcript: This document is a formal request to the registrar's office for the official educational transcripts to be sent directly to the Laboratory Field Services.
Each of these documents plays a vital role in ensuring that applicants meet the necessary requirements for certification as phlebotomy technicians in California. Gathering and submitting these forms accurately can significantly impact the application process and the timeline for obtaining certification.
Similar forms
The California Lab 182 form is a critical document for individuals seeking certification as phlebotomy technicians. It shares similarities with several other documents related to certification and professional licensing. The following list outlines four such documents and their similarities to the Lab 182 form:
- Certified Nursing Assistant (CNA) Application: Like the Lab 182 form, the CNA application requires personal information, proof of education, and documentation of training. Both forms necessitate submission of fees and may include a background check regarding criminal history.
- Medical Assistant Certification Application: This application also demands detailed personal information and educational background. Similar to the Lab 182 form, it requires proof of completion of a training program and successful passage of a certification exam.
- Emergency Medical Technician (EMT) Certification Application: The EMT application shares the requirement for educational documentation and proof of practical training hours. Both forms require applicants to declare their work experience and may include sections for background checks.
- Registered Nurse (RN) Licensure Application: The RN application, like the Lab 182 form, requires comprehensive personal information, proof of education, and verification of clinical training. Both documents also necessitate the payment of application fees and may involve a review of the applicant's criminal history.
Dos and Don'ts
When filling out the California Lab 182 form, it’s essential to follow specific guidelines to ensure your application is processed smoothly. Here are five important dos and don’ts to keep in mind:
- Do ensure that you complete the entire application. An incomplete form will not be evaluated.
- Do attach the required $54 application fee along with two passport-sized photos.
- Do check only one certification category. This helps streamline your application process.
- Don’t send cash. Use a nonrefundable check, cashier’s check, or money order made out to CPS Human Resource Services.
- Don’t forget to send your official documentation of high school graduation or its equivalent directly to the specified address.
By following these guidelines, you can help ensure that your application is complete and ready for review. Remember, attention to detail is key in this process!
Misconceptions
- Misconception 1: The California Lab 182 form can be submitted without all required documents.
- Misconception 2: Only the application fee is required for submission.
- Misconception 3: You can apply for multiple certification categories at once.
- Misconception 4: The processing time for the application is immediate.
- Misconception 5: High school graduation documentation is optional.
- Misconception 6: Any type of payment can be used for the application fee.
- Misconception 7: The application can be filled out in any ink color.
- Misconception 8: Previous criminal convictions do not need to be disclosed.
This is incorrect. Submitting an incomplete application will result in it not being evaluated. All required documentation must be included.
In addition to the application fee, two passport-sized photos must also be attached. Omitting these will delay the process.
The application allows for checking only one certification category. Applicants must choose between Limited Phlebotomy Technician, Certified Phlebotomy Technician I, or Certified Phlebotomy Technician II.
Processing can take at least 60 days, depending on when the fully completed application and official documents are received by the Laboratory Field Services.
Official documentation of high school graduation or its equivalent is mandatory. This must be sent directly to the specified address.
Only a nonrefundable check, cashier’s check, or money order is accepted. Cash payments are not permitted.
Applicants must use blue ink for their signature. This is a specific requirement outlined in the application instructions.
Applicants must disclose any felony or misdemeanor convictions, except for minor traffic violations. Failing to provide this information can impact the application.
Key takeaways
Filling out and using the California Lab 182 form requires careful attention to detail. Here are some key takeaways to consider:
- Complete the Application: Ensure that the application is fully completed. Incomplete submissions will not be evaluated.
- Application Fee: Include a $54 application fee with your submission. Acceptable payment methods are a nonrefundable check, cashier’s check, or money order.
- Documentation Submission: Official documentation of high school graduation or equivalent must be sent directly to the specified address.
- Certification Category: Check only one certification category. Options include Limited Phlebotomy Technician (LPT), Certified Phlebotomy Technician I (CPT I), or Certified Phlebotomy Technician II (CPT II).
- Processing Time: Allow at least 60 days for application processing. This period starts upon receipt of a fully completed application and all required documents.
- Educational Transcripts: Request that your educational transcripts be sent directly from your school to the Laboratory Field Services.
- On-the-Job Experience: Document your on-the-job experience in phlebotomy, including the estimated number of successful punctures.
- Phlebotomy Certification: Attach a copy of the certificate showing that you passed a phlebotomy certification examination from an approved organization.
- Signature Requirement: Sign the application using blue ink and ensure that all statements made are true and correct to avoid forfeiture of rights.