ASCP BOC Phlebotomy Technician (PBT) Examination - Structured Program Completion Verification

Oct 3, 2026

Uploaded by Grenda

Structured Program Completion Verification form for the ASCP BOC Phlebotomy Technician (PBT) Examination. Applicants must provide identity and contact details and then have a qualified supervisor complete and sign program eligibility information. The supervisor verifies completion of a two-part structured phlebotomy training program, including required classroom and clinical components, with specific training hours, dates, and clinical performance requirements. A letter of authenticity on institutional letterhead with a wet signature must also be included.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Applicant Information

Verification of Structured Program Completion

Structured Program Information

Classroom Instruction

Clinical Training

Supervisor Signature and Contact Information

Letter of Authenticity

Applicant Information Must be completed by the applicant Applicant Name: | ASCP Customer ID: | | --- | | Email Address: | | Home Address: | Verification of Structured Program Completion This section must be completed and signed by the applicant’s supervisor† who is qualified to verify the applicant’s structured program completion. †The supervisor is defined as the person who directly oversees the applicant’s technical experience, can verify the applicant’s competency, and who may have titles including supervisor, laboratory manager, program director, educator, etc. This individual, identified above, has applied for the ASCP BOC Phlebotomy Technician (PBT) Examination. To be deemed eligible for this examination, the applicant must have successfully completed a two-part structured phlebotomy training program that includes both classroom instruction and clinical training at an accredited/approved laboratory* . The clinical portion of the two-part program must be arranged by written agreement with the program official and the clinical institution. As the applicant’s supervisor†, please complete the following information: | 1. Structured Program Information | Institution Name:
Institution Address: 6-digit School Code Number (if applicable): | | | --- | --- | --- | | 2. Classroom Instruction
Please place an X by each requirement that has been successfully completed. ALL areas are required for eligibility. | Classroom Training Site:
Classroom Training Beginning Date: Month Day Year
Classroom Training Completion Date: Month Day Year | | | | 40 clock hours of classroom training, including:
Anatomy and physiology of the circulatory system Laboratory operations (e.g., safety, quality control, etc.) | Specimen processing and handling
Specimen collection (including venipunctures and skin punctures) | 3. Clinical Training Please place an X by each requirement that has been successfully completed. ALL areas are required for eligibility. Clinical Training Site at an Approved/Accredited Laboratory*: Clinical Training Beginning Date: Month Day Year Clinical Training Completion Date: Month Day Year Please place an X to indicate that clinical training has been successfully completed, including: Minimum performance of 100 successful unaided venipunctures Orientation in an approved/accredited laboratory* *Acceptable Laboratory: CMS CLIA certificate of registration, compliance, accreditation; OR DoD CLIP certificate of registration, compliance, accreditation; OR JCI accreditation; OR Accreditation under ISO 15189 | 4. Supervisor† Signature and Contact Information
By signing this form, I, as the applicant’s supervisor,† verify that this applicant has successfully completed a two-part structured phlebotomy training program and that all information is accurate to the best of my knowledge. | Supervisor† Name & Credential(s) Supervisor† Signature
Supervisor† Email Address | | | --- | --- | --- | | | | Title | | | | Date | | | | Institution Telephone Number | 5. Letter of Authenticity Include a letter of authenticity from the applicant’s supervisor†. The letter of authenticity must: • Be printed on original institutional letterhead • State that the documentation form was completed, signed, and dated by the supervisor†. • Contain a wet signature †The supervisor is defined as the person who directly oversees the applicant’s technical experience, can verify the applicant’s competency, and who may have titles including supervisor, laboratory manager, program director, educator, etc.

FAQs

Who must complete and sign the structured program verification section?

The applicant’s supervisor, defined as the person who directly oversees the applicant’s technical experience and can verify competency. The supervisor completes the required fields and provides signature and contact information.

What training components are required for eligibility for the PBT examination?

Eligibility requires successfully completing a two-part structured phlebotomy training program: classroom instruction and clinical training at an accredited/approved laboratory.

What clinical training outcomes and laboratory criteria are required?

Clinical requirements include minimum performance of 100 successful unaided venipunctures and orientation in an approved/accredited laboratory. Acceptable laboratories include CMS CLIA, DoD CLIP, JCI, or ISO 15189 accreditation pathways.

Oct 3, 2026

Uploaded by Grenda