Phlebotomy Program Approval Checklist
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| 1. Name of School/Training Facility: |
| 2. Address and Phone of school/training program |
| 3. Title of course |
| 4. Total number of students per class |
| 5. Length of course (hours) |
| 5a. Day(s) of week offered |
| 6. Lecture time (hours) |
| 7. Simulated Lab time (hours) |
| 8. Clinical externship time (hours) |
9. Names and addresses of all participating hospitals and laboratories in the clinical externship setting.
Please submit with an information booklet on each facility.
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3.
4.
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| 10. Person responsible for the trainees/program director |
| 11. Name and title of individual completing application |
11a. Signature of school/training program applicant and title
Address:
Phone: ( )
Date: |