Fillable Office Laboratory Assistant ( APPL ICATION AND CHECKLIST (State of Nevada, Department of Information Technology)

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Office Laboratory Assistant ( APPL ICATION AND CHECKLIST (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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☐Laboratory Assistant
(works in a laboratory that
serves the general public)
☐
Office Laboratory
Assistant (
works in a
physician’s office laboratory)
APPL
ICATION AND
CHECKLIST
Page 1 of 4
Division of Public and Behavioral Health
727 Fairview Drive, Suite E
Carson City, Nevada 89701
Phone: (775) 684-1030 Fax: (775) 684-1075
THIS BOX FOR OFFICAL USE ONLY
COMPLETE THIS FORM. PLEASE FILL IN THIS FORM ELECTRONICALLY, PRINT, SIGN, DATE AND SUBMIT. (If
unable to complete electronically type or print in black or blue ink and submit) Please check one of the boxes
above indicating what type of license you are applying for.
INCOMPLETE APPLICATIONS WILL DELAY PROCESSING OF YOUR CERTIFICATE
INDICATE WHETHER THIS IS AN INITIAL CERTIFICATION OR REACTIVATION OF A CERTIFICATE (check only
one):
☐
Initial Certificate
☐
Reactivation of Certificate
PERSONAL INFORMATION
Name
Maiden/Previous Name (if applicable)
Social Security Number (REQUIRED)
Date of Birth
Email Address
Mailing Address (MUST BE HOME ADDRESS)
PO BOX (If mail undeliverable to home address)
City, State
Zip Code
Phone Number
SEC
TIONS TO BE COMPLETED FOR ALL APPLICATION TYPES
(Regulations governing medical laboratories and laboratory personnel may be found
at: http://leg.state.nv.us/NAC/NAC-652.html)
1
Application Attestations (Check if applicable)
☐If you do not provide a method of electronic communication, such as an e-mail address or any other
method by which to communicate with you other than by telephone or U.S. mail, you must check this box
attesting that this is not feasible and acknowledging that the U.S. mail is the only means which to
communicate with you.
Child Support Information: (Must check one box)
☐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 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 I 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 the district attorney or other public
agency enforcing the order to determine the actions that you may take to satisfy the arrearage.
Your application will be denied if you do not complete this section.
Certified Laboratory Assistant or Office Laboratory Assistant Status (Must check Yes or No)
Do you currently hold a Laboratory Assistant or Office Laboratory Assistant certificate? ☐Yes ☐ No
If Yes, provide your certification number here: _____________________________
INITIAL APPLICANTS COMPLETE THIS SECTION
Initial Laboratory Assistant Applicants only (Complete this section)
I have submitted with my application:
☐ A copy of my High School Diploma or my transcripts with my graduation date or my General Equivalency
Diploma with graduation date (MUST BE INCLUDED)
If submitting a high school diploma from a foreign country, you must submit a letter stating that the
document provided is a high school diploma. The letter must state, “Under penalty of perjury I attest
that the document I have submitted is in fact a copy of my high school diploma.” You must sign and
date this document.
AND you must include proof of completing one of the following (Check one box):
☐ A letter on letterhead or a certificate from a laboratory with a training program approved by the Division of
Public and Behavioral Health which shows you completed 6 months of training; OR
☐ A copy of your Certificate in Phlebotomy from one of the following organizations:
• The American Medical Technologists;
• The American Society for Clinical Pathology;
• The American Certification Agency for Healthcare Professionals;
• The National Center for Competency Testing;
• The National Healthcareer Association; and
• The National Phlebotomy Association; OR
☐ A signed and dated letter on laboratory letterhead from your employer or previous employer that shows
you have worked at least 30 hours per week for at least 3 years in the immediate preceding 5 years in a CLIA
certified laboratory or a laboratory that is licensed by a federal or state governmental agency in any state or
territory of the United States.
2
Initial Office Laboratory Assistant Applicants only:
To be an Office Laboratory Assistant you must be employed by a physician’s office laboratory in Nevada (prior
to application). You MUST COMPLETE the information below.
The Laboratory Directing Physician must sign here:
Print name of Directing Physician: ____________________________________________
Directing Physician’s Signature: ___________________________________ Date: __________
IF YOU ARE APPLYING FOR A REACTIVATION OF A CERTIFICATE YOU MUST COMPLETE THIS SECTION
(Must check both boxes)
☐I have submitted with my application copies of my CEU certificates which add up to 10 CEU contact hours.
☐ I certify it has been 5 years or less since my certification has expired.
Note: If it has been more than 5 years since your certification has expired you must apply as an Initial
Applicant by completing the initial applicant’s section in the category for which you are applying.
Previous Certification Number: ___________________________ Expiration Date: _______________
I understand that knowingly making a false statement on this application will be cause for denial, suspension,
or revocation of licensure. I have examined this application and it is complete. I declare under penalty of
perjury that the foregoing is true and correct.
Executed on:
Applicant’s Signature: _________________________________ Date: ________________
ALL APPLICANTS MUST SUBMIT, WITH YOUR APPLICATION, TO THE ADDRESS PROVIDED BELOW:
☐A completed, signed and dated application.
☐A $60 fee via personal check, cashier’s check or money order paid to the order of Nevada State Treasurer.
☐All documents required to be submitted with this application.
LABORATORY INFORMATION
Employer/Laboratory Name
Nevada Lab License Number
Laboratory Street Address
City
State
Zip Code
Laboratory Phone Number
Laboratory Fax Number
3
Notes:
Certificate issued is valid for two (2) years after the date on which it was issued.
You may work as a temporary employee for a period not exceeding 6 months while the application is
being processed.
It is your responsibility to renew your certification before it expires, regardless of whether you receive
a renewal notification or not.
Allow up to six months processing time.
If insufficient funds are submitted a $25 fee will be assessed.
Submit completed application, including all requested documentation and fee to:
Division of Public and Behavioral Health
Medical Laboratory Services
727 Fairview Drive, Suite E
Carson City, NV 89701
If you have any questions please contact 775-684-1030 and request the Medical Laboratory Services.
Change of Information - Click on Change of Name or Address Form: http://dpbh.nv.gov/uploadedFiles/
dpbhnvgov/content/Reg/MedicalLabs/Docs/Applications/changeofaddress.pdf
You must notify the Division of any change to the information contained in your application within 30 days
after the change. Failure to comply with this requirement is grounds for denial of your application or the
suspension or revocation of your license, as applicable.
4
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Office Laboratory Assistant ( APPL ICATION AND CHECKLIST (State of Nevada, Department of Information Technology)

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Completed 1 March 2022

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