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H Route 1, 2 شهادة خبرة

This document is an Experience Documentation Form for applicants seeking certification as an International Technologist in Hematology. It requires the applicant's personal information and verification of their hematology experience by laboratory management or employer, including specific procedures performed. A letter of authenticity from the employer is also necessary for the form to be accepted.

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38 views1 page

H Route 1, 2 شهادة خبرة

This document is an Experience Documentation Form for applicants seeking certification as an International Technologist in Hematology. It requires the applicant's personal information and verification of their hematology experience by laboratory management or employer, including specific procedures performed. A letter of authenticity from the employer is also necessary for the form to be accepted.

Uploaded by

gaber 230
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INTERNATIONAL TECHNOLOGIST IN HEMATOLOGY

EXPERIENCE DOCUMENTATION FORM (Routes 2 & 4)

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 IN ORDER TO


BE ACCEPTABLE)
SUBJECT: VERIFICATION OF EXPERIENCE FOR EXAMINATION ELIGIBILITY
This individual, identified above, has applied for the Board of Certification International Technologist in Hematology
examination. In order to establish this applicant’s eligibility for certification, the following information is necessary:
1. PLEASE COMPLETE: EXPERIENCE (INCLUDING ON-THE-JOB TRAINING)
Date experience started in Hematology: Month Day Year
Date experience ended in Hematology: Month Day Year
How many hours per week in Hematology? (average, if necessary)
2. DIRECTIONS: Please review the experience of this applicant.
A. Please place an X by each procedure that has been performed satisfactorily under your supervision by this
applicant. (NOTE: Experience is required in ALL of the procedures listed below.)
Blood smear, evaluation and differential Quality control: performance and evaluation
Complete blood count Routine coagulation tests (e.g., PT, APTT, D-dimer)
B. Please place an X by each procedure that has been performed satisfactorily under your supervision by this
applicant. (NOTE: Experience is required in 2 of the 3 areas listed below.)
Instrument maintenance / troubleshooting
Miscellaneous tests (e.g., ESR, sickle screen, manual cell count, reticulocyte)
Other coagulation tests (e.g., fibrinogen, factor assays, hypercoagulability)
3. BY SIGNING THIS FORM, I AS LABORATORY MANAGEMENT* OR EMPLOYER VERIFY THAT THIS APPLICANT IS
PROFICIENT IN EACH OF THE HEMATOLOGY 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: Jan 2022 | Page 1 of 1

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