California statement of phlebotomy practical training form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the laboratory information. Enter the name, address, email, and telephone number of the laboratory where the training took place.
3. Next, provide your personal details in the applicant information section. Fill in your name, social security number, address, and telephone number.
4. Indicate the dates of your training experience by entering the start and end dates in the designated fields.
5. In the proficiency section, ensure you check off each area where you have demonstrated skills. This includes blood collection equipment selection and patient preparation.
6. Complete the procedure requirements by indicating successful skin punctures and venipunctures as applicable. Make sure to document any arterial punctures if required.
7. Finally, have your supervisor sign and date the form along with their printed name and title. Ensure that the laboratory director also signs and provides their details.

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