CLINICAL LABORATORY PERSONNEL CERTIFICATION APPLICATION NEVADA STATE HEALTH DIVISION Bureau of Health Care Quality and Compliance 727 Fairview Drive, Suite E Carson City, Nevada 89701 Phone: (775) 684-1030 Fax: (775) 684-1075 http://www.health.nv.gov/HCQC_Medical.htm Page 1 of 2 This application must be accompanied by a check for the appropriate amount made payable to the Nevada State Health Division. Under Nevada Administrative Code (NAC) 652.488 the fee is non-refundable. Insufficient funds charge: $25.00 per NAC 353C.400. Failure to submit appropriate documentation within six (6) months of application submission voids the application. Regulations may be viewed at http://leg.state.nv.us. PLEASE SUBMIT ANY CHANGES IN WRITING WITHIN 30 DAYS OF THE CHANGE. Initial Reactivation* *1 CEU required (5 approved, 5 unapproved) (excluding Office Lab Assistants) New Level of Certification Previous Certification Number: Name PERSONAL INFORMATION LABORATORY INFORMATION Employer/Laboratory Name Maiden/Previous Name (if applicable) Nevada Lab License Number Social Security Number (REQUIRED) Laboratory Street Address Mailing Address (MUST BE HOME ADDRESS) City City County County State State Zip Code Zip Code Laboratory Phone Number (starting with the area code) Date of Birth (i.e., 08/12/1965) Laboratory Fax Number (starting with the area code) Phone Number (starting with the area code) ALL APPLICANTS MUST COMPLETE THIS SECTION Failure to clearly mark one of the choices below will result in denial of the application. Federal Welfare Reform as implemented by the 1997 Legislative Session NRS 652.095 requires that professional and occupational licensing agencies add the following questions regarding child support to all applications for new licenses and renewals. Your license, issued by the Bureau, is subject to this requirement mandated by the Federal Government of all states, including Nevada. MUST CHOOSE ONLY ONE BOX Please mark the appropriate response: I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and am in compliance with the order, or am in compliance with a plan approved by the district attorney or other public agency enforcing the order for repayment of the amount owed pursuant to the order. I am subject to a court order for the support of one or more children and am not in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. You are required to contact your local District Attorney or the Welfare Division to arrange payment. Provide evidence of compliance and payment with the application. I hereby certify that all the above statements/information are true, correct and complete to the best of my knowledge. Applicant’s Signature: Date: If you fail to answer the questions or sign this form, your license will NOT be issued and the fee will NOT be refunded. 11/30/2010 American LegalNet, Inc. www.FormsWorkFlow.com CLINICAL LABORATORY PERSONNEL CERTIFICATION APPLICATION Page 2 of 2 PLEASE CHECK APPROPRIATE BOX Assistant - $60.00 Laboratory Assistant for Licensed Labs (must include copy of high school diploma or GED per NRS 652.127) *Reactivation CEU must be 10 contact hours Blood Gas Assistant (must include copy of high school diploma or GED per NAC 652.450) Office Laboratory Assistant for Exempt or Registered Labs _____________________________________________ ______________________________________________ Please PRINT Directing Physician’s Name Directing Physician’s SIGNATURE (Physician’s signature only needed for Office Laboratory Assistant applications) General Supervisor - $225.00 Evidence is required of at least 3 years full-time experience at the technologist level and evidence of passing the national exam for a technologist, 2 years of experience with a Masters Degree or 1 year experience with a PhD (NAC 652.410). *Technologist - $113.00 Clinical Laboratory Technologist Blood Gas Technologist Histotechnologist Cytotechnologist Specialty Technologist Chemistry Microbiology Hematology Immunology Immunohematology Nuclear Medicine Histocompatibility Histology Cytology Biotechnologist *Technician - $113.00 Medical Technician Blood Gas Technician Histologic Technician Specialty Technician Chemistry Microbiology Hematology Immunology Nuclear Medicine Histocompatibility Histology Autopsy Assistant Biotechnician *Pathologist Assistant - $113.00 Pathologist Assistant *Proof of passing the national exam and official transcripts when required. Point of Care Analyst - $75.00 Applicants must attach verifications of completion of a director approved training program and a copy of their professional license. Academic Background (NAC 652.470): College/University City State Degree Obtained Laboratory Training and/or Work Experience (NAC 652.470): Company Name City State Work Title Major Supervisor’s Name From Month/Year Month/Year To Month/Year For Official Use Only: 11/30/2010 American LegalNet, Inc. www.FormsWorkFlow.com