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Ic Doc Form Routes 2and4 2

This document is an experience documentation form for an international technologist in chemistry applicant. It requires the applicant's information and verification by a laboratory manager or employer of the applicant's dates of experience in chemistry, average hours worked per week, and proficiency in 8 of 15 listed chemistry procedures, including blood gases, carbohydrates, electrolytes, and quality management. The manager must sign, print their information, and include an original letter of authenticity on laboratory letterhead stating they completed the form.

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مصطفي خندقاوي
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45 views1 page

Ic Doc Form Routes 2and4 2

This document is an experience documentation form for an international technologist in chemistry applicant. It requires the applicant's information and verification by a laboratory manager or employer of the applicant's dates of experience in chemistry, average hours worked per week, and proficiency in 8 of 15 listed chemistry procedures, including blood gases, carbohydrates, electrolytes, and quality management. The manager must sign, print their information, and include an original letter of authenticity on laboratory letterhead stating they completed the form.

Uploaded by

مصطفي خندقاوي
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 CHEMISTRY

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 Chemistry
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 Chemistry: Month Day Year
Date experience ended in Chemistry: Month Day Year
How many hours per week in Chemistry? (average, if necessary)

2. DIRECTIONS: Please review the experience of this applicant. Please place an X by each procedure that has been
performed satisfactorily including pre-analytical, analytical and post-analytical phases of testing under your
supervision by this applicant. (NOTE: Experience is required in 8 of the 15 procedures listed below.)
Blood gases Heme compounds Point-of-care
Carbohydrates Hormones/vitamins Proteins
Electrolytes Immunochemistry Quality management
Electrophoresis Lipids/lipoproteins Therapeutic drug monitoring
Enzymes Non-protein nitrogen compounds Toxicology

3. BY SIGNING THIS FORM, I AS LABORATORY MANAGEMENT* OR EMPLOYER VERIFY THAT THIS APPLICANT IS
PROFICIENT IN EACH OF THE CHEMISTRY 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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