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#22-000305-0002
Supplemental Questionnaire

Last Name
First Name

 

**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1
Do you have an associate degree or higher in a Laboratory Science or Medical Laboratory Technology from an accredited college or university?
Yes No
2

If you answered "No" for question 1, do you possess 60 credits from an accredited college or university which includes either of the following:

(Please attach a transcript with your application which supports your response.)

24 credits in medical laboratory technology.
24 credits of science courses including 6 credits in chemistry, 6 credits in biology, and 12 credits in any combination of chemistry, biology or medical technology.
Not applicable.
3
If you answered "No" for question 1, have you completed an approved clinical laboratory training program or at had least three months of laboratory training performing high complexity testing?
Yes
No
Not applicable.
4

Please describe your training from question 3.  Include dates in your answer.  (If this does not apply, type N/A.)

5

Describe your professional experience performing public health, medical, or environmental laboratory testing. 

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below. 

6

Describe your experience with histology and neuropathology.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

7

Describe your knowledge of and experience with grossing and embedding specimens.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

8

Describe your experience with medical terminology, basic inorganic chemistry applications to public health laboratory.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

9

Describe your experience using basic laboratory equipment and instruments.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

10

Describe your experience performing analytical tests.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

11

Describe your knowledge of and/or experience with microtomy (cutting of tissue using microtome).

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

 

12

Describe your knowledge of and/or experience with staining tissue.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.


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