[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-186694-en":3,"doc-seo-186694-105":30,"detail-sidebar-cat-0-en-105":91},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":4,"category_id":11,"category_name":12,"doc_title":13,"doc_description":14,"doc_content":15,"file_id":16,"file_url":17,"file_type":18,"file_size":19,"view_count":20,"is_deleted":4,"is_public":20,"is_downloadable":20,"audit_status":20,"page_count":21,"language":22,"language_code":23,"site_id":24,"html_lang":23,"table_of_contents":25,"faqs":26,"seo_title":27,"seo_description":14,"update_tm":28,"read_time":29},186694,4398048950312,"Violet","https://ap-avatar.wpscdn.com/avatar/400002538284de19e3c?_k=1778320343897328908",7,"Healthcare","Clinical Laboratory Technologist Restricted License Form 4 - Attestation of Training Program Content in Cytogenetics","Restricted license attestation form for a Clinical Laboratory Technologist applying for New York State cytogenetics training. Applicants and the cytogenetics training program director must complete Section I applicant details and Section II training program information, including director qualifications and facility permit verification. The program director attests that required cytogenetics training topics are covered, at least 1,750 hours are provided, supervision requirements are met, and the training is limited to authorized hands-on services within the cytogenetics restricted license category.","The University of the State of New YorkThe State Education DepartmentOffice of the ProfessionsDivision of Professional Licensing Serviceswww.op.nysed.gov  \nClinical Laboratory Technologist Restricted License Form 4Attestation of Training Program Content in Cytogenetics  \n# Applicant Instructions\n\nComplete Section I.Review and complete Section ll with the Director of the Cytogenetics Training Program in which you want to participate.Be sure to sign and date the applicantattestation and ask the Training Program Director to returnall pages of the form to the Office of theProfessions at the address at the end of the form.This form will not be accepted if returned by the applicant.Section l:Applicant Information  \n1.Social Security Number2.Birth DateMonth[Day(Leave this blank if you do not have a U.S.Social Security Number)First  \nMiddle5.Telephone/Email Address  \nDaytime PhoneHome or  \nLicensee business address,phone and email address are public information.Failure toindicate business or home on this form for each item will deem it public information.  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |  |\n| --- | --- | --- |\n\n\n|  |  |  |\n| --- | --- | --- |\n\nArea Code  \nPhone  \n4.Mailing Address □Home or □ Business  \n(You must notify the Department within 30 days of any address or name changes)Email Address (please print clearly)Line 1Line 2Line 3  \n6.New York State DMV ID NumberCityStateZIP Code                  \n(Driver or Non-Driver ID)  \n\n|  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\n(Leave this blank if you do not have aCountrylProvinceNew York State DMV ID Number)  \n# Section II:Training Program Information\n\n1.Name of Clinical Laboratory offering the Training Program  \nAddress of Clinical Laboratory  \nNew York State Department of Health(DOH)Clinical Laboratory Permit Number  \nIndicate whether the Cytogenetics testing is authorized by the DOH issued Clinical Laboratory Permit  \n□Yes □NoContact Email Address                                           Contact Telephone Number                                                                                  Check Each that apply  \n2.Name of Cytogenetics Training Program Director  \n□I hold a DOH issued Laboratory Director Certificate of Qualification in Cytogenetics.  \n□lam the Clinical Laboratory Director of the Clinical Laboratory described above.  \n□lam a sole Assistant Clinical Laboratory Director at the Clinical Laboratory described above.  \nCLT Restricted License in Cytogenetics Form 4,Page 1 of 2,Revised 2124  \n# Section II:Training Program Information(Continued)\n\n3.The applicant and the training program director must initial below indicating that all the following training program requirements will be met.  \nThe Training Program will cover:(a)human genetics and clinical cytogenetics,including chromosome structure/behavior and itscorrelation withphenotype;(b)laboratory principles and skills,including infection control,aseptic technique,quality control,qualityassurance,use and maintenance of instruments,and laboratory mathematics;(c)specimen processing,including sample preparation,culturing,harvesting,slide preparation,staining,and chromosomal banding techniques;(d)chromosome analysis and imaging,includingrecognition and interpretation of chromosomal abnormalities;and (e)molecular cytogenetic testing methods,such as chromosomalmicroarray analysis,and/or metaphase and interphase fluorescence in situ hybridization (FISH).The Training Program will only includehands-on laboratory services authorized by a Department of Health Clinical Laboratory permit in the category of Cytogenetics.  \n# Training Program Director Initials          \n\nApplicant Initials              \nThe Training Program will be at least 1750 hours(1 year)and will not involve any testing or procedures on specimens which are outsidethe restricted license category of Cytogenetics.  \n# Training Program Director Initials          \n\nThe Training Program will provide continuous on","cbCaivrSMhCTJ6V6","https://ap.wps.com/l/cbCaivrSMhCTJ6V6","pdf",744184,1,2,"English","en",105,"# Applicant Instructions\n## Section I: Applicant Information\n## Section II: Training Program Information\n## Training Program Director Initials\n## Applicant Attestation\n## Training Program Director Attestation","[{\"question\":\"What must the applicant do with this restricted license form?\",\"answer\":\"Complete Section I and have Section II reviewed and completed with the cytogenetics training program director. Sign and date the applicant attestation, and ensure all pages are returned by the training program to the Office of the Professions (not by the applicant).\"},{\"question\":\"What training program details are required in Section II?\",\"answer\":\"Provide the clinical laboratory name and address, the DOH Clinical Laboratory Permit number, confirm whether cytogenetics testing is authorized, and list the cytogenetics training program director details and qualifications.\"},{\"question\":\"What training requirements must the director attest to?\",\"answer\":\"The director must confirm the program covers specified cytogenetics topics, is at least 1,750 hours, limits activities to the cytogenetics restricted license category, and provides continuous on-site personal supervision by qualified staff.\"}]","Clinical Laboratory Technologist Restricted License Form 4 - Attestation of Training Program Content in Cytogenetics | PDF",1788376097,5,{"code":4,"msg":31,"data":32},"ok",{"site_id":24,"language":23,"slug":33,"title":13,"keywords":34,"description":14,"schema_data":35,"social_meta":86,"head_meta":88,"extra_data":90,"updated_unix":28},"clinical-laboratory-technologist-restricted-license-form-4-attestation-of-training-program-content-in-cytogenetics","",{"@graph":36,"@context":85},[37,53,68],{"@type":38,"itemListElement":39},"BreadcrumbList",[40,44,47,50],{"item":41,"name":42,"@type":43,"position":20},"https://docshare.wps.com","Home","ListItem",{"item":45,"name":46,"@type":43,"position":21},"https://docshare.wps.com/document/","Document",{"item":48,"name":12,"@type":43,"position":49},"https://docshare.wps.com/document/healthcare/",3,{"item":51,"name":13,"@type":43,"position":52},"https://docshare.wps.com/document/clinical-laboratory-technologist-restricted-license-form-4-attestation-of-training-program-content-in-cytogenetics/186694/",4,{"url":51,"name":13,"@type":54,"author":55,"headline":13,"publisher":57,"fileFormat":60,"inLanguage":23,"description":14,"dateModified":61,"datePublished":62,"encodingFormat":60,"isAccessibleForFree":63,"interactionStatistic":64},"DigitalDocument",{"name":9,"@type":56},"Person",{"url":41,"name":58,"@type":59},"DocShare","Organization","application/pdf","2026-09-04","2026-09-02",true,{"@type":65,"interactionType":66,"userInteractionCount":20},"InteractionCounter",{"@type":67},"ViewAction",{"@type":69,"mainEntity":70},"FAQPage",[71,77,81],{"name":72,"@type":73,"acceptedAnswer":74},"What must the applicant do with this restricted license form?","Question",{"text":75,"@type":76},"Complete Section I and have Section II reviewed and completed with the cytogenetics training program director. Sign and date the applicant attestation, and ensure all pages are returned by the training program to the Office of the Professions (not by the applicant).","Answer",{"name":78,"@type":73,"acceptedAnswer":79},"What training program details are required in Section II?",{"text":80,"@type":76},"Provide the clinical laboratory name and address, the DOH Clinical Laboratory Permit number, confirm whether cytogenetics testing is authorized, and list the cytogenetics training program director details and qualifications.",{"name":82,"@type":73,"acceptedAnswer":83},"What training requirements must the director attest to?",{"text":84,"@type":76},"The director must confirm the program covers specified cytogenetics topics, is at least 1,750 hours, limits activities to the cytogenetics restricted license category, and provides continuous on-site personal supervision by qualified staff.","https://schema.org",{"og:url":51,"og:type":87,"og:title":13,"og:site_name":58,"og:description":14},"article",{"robots":89,"canonical":51},"index,follow",{"doc_id":7,"site_id":24},{"code":4,"msg":5,"data":92},[93,97,101,105,109,114,117,122,127,130,134],{"id":20,"doc_module":4,"doc_module_name":46,"category_name":94,"show_sort_weight":95,"slug":96},"Story & Novel",90,"story-novel",{"id":21,"doc_module":4,"doc_module_name":46,"category_name":98,"show_sort_weight":99,"slug":100},"Literature",80,"literature",{"id":52,"doc_module":4,"doc_module_name":46,"category_name":102,"show_sort_weight":103,"slug":104},"Exam",70,"exam",{"id":29,"doc_module":4,"doc_module_name":46,"category_name":106,"show_sort_weight":107,"slug":108},"Comic",60,"comic",{"id":110,"doc_module":4,"doc_module_name":46,"category_name":111,"show_sort_weight":112,"slug":113},6,"Technology",50,"technology",{"id":11,"doc_module":4,"doc_module_name":46,"category_name":12,"show_sort_weight":115,"slug":116},40,"healthcare",{"id":118,"doc_module":4,"doc_module_name":46,"category_name":119,"show_sort_weight":120,"slug":121},8,"Research & Report",30,"research-report",{"id":123,"doc_module":4,"doc_module_name":46,"category_name":124,"show_sort_weight":125,"slug":126},9,"Religion & Spirituality",20,"religion-spirituality",{"id":125,"doc_module":4,"doc_module_name":46,"category_name":128,"show_sort_weight":125,"slug":129},"World Cup","world-cup",{"id":131,"doc_module":4,"doc_module_name":46,"category_name":132,"show_sort_weight":131,"slug":133},10,"Lifestyle","lifestyle",{"id":135,"doc_module":4,"doc_module_name":46,"category_name":136,"show_sort_weight":29,"slug":137},19,"General","general"]