Instructor Program Approval Checklist
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| 1. Name and title of individual applying for application: |
| 2. Address and Phone of individual applying for application |
3. Name of school/training facility where training is to be held
address and phone number: ( ) |
| 4. Title of course |
| 5. Total number of students per class |
| 6. Length of course (hours) |
| 6a. Day(s) of week offered |
| 7. Lecture time (hours) |
| 8. Simulated Lab time (hours) |
| 9. Clinical externship time (hours) |
10. 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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4.
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| 11. Person responsible for the trainees/program director |
| 12. Applicant's schedule in the school/training facility |
13. Applicant's duties/responsibilities:
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Signature of Applicant:
Address:
Phone: ( )
Date: |
Please submit the following along with completed application:
1. Must be registered laboratory medical technologist/technician, A.S.P.T. certified phlebotomist, certified medical assistant, or registered nurse.
2. Proof of A.S.P.T. certification with at least 93 percent or waivered in with a successful practical or 90% or greater.
3. Current A.S.P.T. member
4. Must be certified in CPR and maintain certification.
5. Must have at least 5 years experience in the laboratory environment, performing technical processes and related lab work.
6. Must submit 3 letters of reference attesting to experience in the laboratory environment and teaching and training of Phlebotomy/Lab Personnel.
7. Current resume
8. Proof of at least six (6) hours of medical continuing education during the pervious year.
9. Must submit a detailed course outline of how you teach the program, including lessons plans.
10. A properly filled out enclosed application.
11. A $75.00 annual application fee. Upon receipt of fee and application, the application will be reviewed. Upon approval, an A.S.P.T. Approval Instructor Certificate will be awarded. This must be renewed annually. |