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Imb Routes 4 and 5 Work

This document is an experience documentation form for applicants seeking certification as an International Technologist in Molecular Biology. It requires information about the applicant's molecular biology work experience, including dates and hours worked. The applicant's laboratory management or employer must verify the areas of molecular biology the applicant has experience in, such as genetics/genomics, oncology, or infectious disease. The management or employer signs the form to confirm the applicant's experience and proficiency in the checked areas.

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0% found this document useful (0 votes)
72 views1 page

Imb Routes 4 and 5 Work

This document is an experience documentation form for applicants seeking certification as an International Technologist in Molecular Biology. It requires information about the applicant's molecular biology work experience, including dates and hours worked. The applicant's laboratory management or employer must verify the areas of molecular biology the applicant has experience in, such as genetics/genomics, oncology, or infectious disease. The management or employer signs the form to confirm the applicant's experience and proficiency in the checked areas.

Uploaded by

sjbfhsbv
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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INTERNATIONAL TECHNOLOGIST IN MOLECULAR BIOLOGY

EXPERIENCE DOCUMENTATION FORM (Routes 4 & 5)

PART I (TO BE COMPLETED BY APPLICANT)

Applicant’s Name ASCP Customer ID #

Email Address Address

PART II (MUST BE COMPLETED AND SIGNED BY LABORATORY MANAGEMENT* OR EMPLOYER TO BE ACCEPTABLE)


SUBJECT: VERIFICATION OF EXPERIENCE FOR EXAMINATION ELIGIBILITY
This individual, identified above, has applied for the Board of Certification International Technologist in Molecular Biology examination.
To establish this applicant’s eligibility for certification, the following molecular biology laboratory** experience information is
necessary:
1. PLEASE COMPLETE: EXPERIENCE (INCLUDING ON-THE-JOB TRAINING)
Date experience started in molecular biology: Month Day Year
Date experience ended in molecular biology: Month Day Year
How many hours per week in molecular biology? (average, if necessary)
2. DIRECTIONS: Please review the experience of this applicant. Please place an X by each area in which this applicant has
demonstrated proficiency under your supervision in a molecular biology laboratory**.
** A molecular biology laboratory is defined as one capable of providing individuals with knowledge and practical experience in
all aspects of molecular methods including, but not limited to, nucleic acid isolation, amplification, detection, sequencing,
hybridization techniques, and data analysis.
(NOTE: Experience is required in at least 1 of the 5 areas listed below.)
Genetics/genomics (e.g., genotyping, gene disorders, pharmacogenomics, genome-wide analysis)
Oncology (e.g., hematologic lymphoid neoplasms/neoplasia, solid tumor gene markers)
Infectious disease (e.g., molecular microbiology/virology, epidemiology)
Molecular identity testing (e.g., engraftment, paternity)
Informatics for clinical laboratory test interpretation and teporting (e.g., genetics/genomics,
oncology, infectious disease, or molecular identity testing)
3. BY SIGNING THIS FORM, I AS LABORATORY MANAGEMENT* OR EMPLOYER VERIFY THAT THIS APPLICANT HAS PERFORMED
SATISFACTORILY IN THE MOLECULAR BIOLOGY AREAS CHECKED ON THIS FORM.

(Please Print) Laboratory Management* or Employer Name Title

Laboratory Management* or Employer Signature Date

Laboratory Management* or Employer Email Address Institution Telephone Number

Institution

Institution Address
BE SURE TO INCLUDE A LETTER OF AUTHENTICITY FROM YOUR LABORATORY MANAGEMENT* OR EMPLOYER WITH THIS
EXPERIENCE DOCUMENTATION FORM. THE LETTER OF AUTHENTICITY MUST BE PRINTED ON ORIGINAL LETTERHEAD. IT MUST STATE
THAT THE EXPERIENCE DOCUMENTATION FORM WAS COMPLETED, SIGNED AND DATED BY YOUR LABORATORY MANAGEMENT*
OR EMPLOYER. EXPERIENCE DOCUMENTATION FORMS RECEIVED WITHOUT LETTERS OF AUTHENTICITY ARE UNACCEPTABLE.
*Management is defined as someone in a management role who can verify technical experience.
See www.ascp.org/boc/intl-documentation for submission instructions.

ASCP BOC International 33 West Monroe Street, Suite 1600, Chicago, IL 60603 | www.ascp.org/international | Revised: July 2022 | Page 1 of 1

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