THIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the student's name and ID number in the designated fields at the top of the form.
  3. Select the student's gender by checking either 'Male' or 'Female'.
  4. Fill in the school name, date of birth, grade, and place of birth (city, state, country) in the respective sections.
  5. Indicate if the student is of Hispanic origin by selecting 'Yes' or 'No', and choose their racial group from the options provided.
  6. Complete the parent/guardian information section with names, address, and contact numbers.
  7. Answer questions regarding language usage at home. If another language is spoken, specify which one and how often it is used compared to English.
  8. Provide details about your child's enrollment date in a U.S. school and sign at the bottom of the form.

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CLIA regulations establish quality standards for laboratory testing performed on specimens from humans, such as blood, body fluid, and tissue. This is done for the purpose of diagnosis, prevention, or treatment of disease, or assessment of health. Clinical Laboratory Improvement Amendments (CLIA) - CDC Centers for Disease Control and Prevention | CDC (.gov) clia php about Centers for Disease Control and Prevention | CDC (.gov) clia php about
Youll need to pay your CLIA certification fee every two years to maintain your CLIA certificate. CLIA Certification - CMS CMS clia howobtaincliacertificate CMS clia howobtaincliacertificate
CLIA applies to, and requires certification of, all facilities that perform any tests on materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings (see 42 U.S.C. 263(a)). CLIA Certification Guidance - Division of Research and Innovation Division of Research and Innovation - Oregon State University ori irb clia-certifica Division of Research and Innovation - Oregon State University ori irb clia-certifica
California Waived: $2,500; In/Out-of-State License Applications: $5,500.
CLIA is the acronym for the Clinical Laboratory Improvement Amendments of 1988. This law requires any facility performing examinations of human specimens (e.g., tissue, blood, , etc.) for diagnosis, prevention, or treatment purposes to be certified by the Secretary of the Department of Health and Human Services. QUESTIONS AND ANSWERS ON THE CLIA - CMS CMS CLIA downloads cliaback CMS CLIA downloads cliaback
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