New Jersey Department of Health

Clinical Laboratory Improvement Services

PO Box 361

Trenton, NJ 08625-0361

LABORATORY PERSONNEL QUALIFICATION APPRAISAL

An individual employed in a clinical laboratory as director, general supervisor, technical supervisor, technologist, cytotechnologist, cytotechnologist supervisor, or technician, must establish his/her qualifications under N.J.S.A. 45:9-42.34. The Clinical Laboratory Improvement Services needs the following information to determine whether the employer listed in Item 3 meets the requirements for qualified personnel. Authority to collect the information is given in N.J.S.A. 45:9-42.3 Right of Entry and Inspection. The information you furnish will be used for: (1) routine administrative processes carried out in accordance with established regulations and published notices of systems of records, and (2) disclosures expressly permitted by the Privacy Act without the individual's consent, e.g., to the Bureau of the Census. The information will not be released to any persons or organizations outside of official administrative channels unless the individual specifically requests in writing that such disclosures be made (Privacy Act of 1974 - Public Law 93-579).

Verification of degree, diploma, board certification, etc., may be requested.

1.	Name (Last, First, Middle)

2.	Maiden Name (if Married)

Home Mailing Address

City	State	Zip Code

3.	Name of Present Employer

Address

City	State	Zip Code

4.	Employment Work Arrangements	5.	Shift

Day Evening Night
Full Time	Part Time
Call or Call Back	Hours/Week:
6.	Positions Currently Held in Laboratory

Director	Technologist

General Supervisor	Cytotechnologist

Cytotechnologist Supervisor	Technician

Technical Supervisor	Phlebotomist

7.	Technical Supervisors ONLY - Check the following in which you presently function:

Microbiology	Endocrinology

Diagnostic Immunology	Virology

Chemistry	Toxicology

Hematology	Cytology

Immunohematology	Cytogenetics
8a. High School Graduate or Equivalent

Yes No
College, University or Other Schools Attended
8b. Name and Address

of Institution	From	To	Major	Degree, Diploma or Certificate	Conferred
Mo.	Yr.	Mo.	Yr.
Mo.	Yr.

9. Clinical Laboratory Training

(Training fulfilling or partially fulfilling a Degree, Diploma, or Certificate requirement listed in Item 8.)
Name and Address	From	To	Program Title	Degree, Diploma or Certificate	Conferred
Mo.	Yr.	Mo.	Yr.
Mo.	Yr.
10. License, Certification or Registration

(Attach copies of any licenses, certifications and/or registrations held.)
11. Clinical Laboratory Experience
Name and Address

of Laboratory or Institution

Begin with earliest employment and continue through present employment. Any gaps in employment will be assumed to be non-clinical laboratory work periods.

Attach additional pages if necessary.	Period

Employed	Position

Held *

[* Indicate position(s) as shown in Item 6.]	Microbiology	Diagnostic Immunology	Chemistry	Hematology	Cytology	Endocrinology	Toxicology	Virology	Immunohematology	Cytogenetics	Other
From	To
Mo.	Yr.	Mo.	Yr.
- READ THE FOLLOWING CAREFULLY BEFORE SIGNING -

Statements or entries generally: Whoever, in any matter within the jurisdiction of any department or agency of the State of New Jersey knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statements or entry, shall be subject to a penalty of not less than $100.00 or more than $1000.00 for each violation (N.J.S.A. 2A:58-10 through 12).
CERTIFICATION

I CERTIFY that all of the statements made in this form are true, complete and correct to the best of my knowledge and belief and are made in good faith.
12. Signature of Applicant	Date
CERTIFICATION

I have reviewed the entries made herein and to the best of my knowledge they are true, complete and correct.
13. Signature of Current Laboratory Director	Date

LABORATORY PERSONNEL QUALIFICATION APPRAISAL

(Continued)

CL-34

SEP 15	Page 2 of 2 Pages.

SEP 15	Page 1 of 2 Pages.

CL-34, Laboratory Personnel Qualification Appraisal

CL-34, laboratory, personnel, qualification, clinical laboratory improvement, CLIS, CL

ewhite

2015-08-28

NJDOH