CQ _Initial_App_Inst_01262024

CLINICAL LABORATORY EVALUATION PROGRAM
APPLICATION INSTRUCTIONS
BIGGS LAB – WADSWORTH CENTER FOR
NYS DEPARTMENT OF HEALTH CERTIFICATE OF QUALIFICATION
EMPIRE STATE PLAZA
ALBANY, NEW YORK 12237
E-Mail: CLEPCQ@health.ny.gov
Web: www.wadsworth.org/regulatory/clep
Please read and follow the instructions carefully. Incomplete or incorrectly completed applications will delay processing.
1. PERSONAL INFORMATION
Provide all information requested. Authority for the Clinical Laboratory Evaluation Program to request personal information, including
identifying information such as Social Security Number, and the authority to maintain such information is found in Section 5 of the New
York State Tax Law. Disclosure of this information is mandatory. This information will be used for tax administration purposes and for
any other purposes authorized by the Tax Law. The administrator of the Clinical Laboratory Evaluation Program is responsible for
maintaining records of such information. The administrator can be reached in writing at the address listed above. E-mail addresses will
be used to send electronic correspondence concerning the status of your application or that of a laboratory at which you are employed
and will not be used for any other purpose.
2. GRADUATE/PROFESSIONAL EDUCATION
List all medical and graduate schools attended in chronological order indicating the degree received. Applicants with an earned doctoral
degree in a chemical, physical, or biological science must provide an original transcript of their doctoral studies. Doctoral degrees
earned at foreign colleges or universities must be evaluated for equivalency to the requirements of schools in the United States. The
Department will accept credential equivalency evaluations from any of the organizations listed as members of the National Association
of Credential Evaluation Services (www.naces.org) or the Association of International Credential Evaluators, Inc. (www.aice-eval.org).
Please refer to the websites for current listings of member organizations, as this list is subject to change. Evaluations are valid only if
received in the evaluating agency’s sealed envelope or directly from the evaluating agency.
3. BOARD CERTIFICATION
New York State regulations recognize only those Boards listed below. On the application, please enter the abbreviation of board
and specialty (see below) and date (re)certified. Applicants must provide a copy of their board certificate(s) and any recertifications.
ABBREVIATIONS FOR ACCEPTED BOARD CERTIFICATIONS:
ABB(HLCD) American Board of Bioanalysis as High Complexity Laboratory Director

ABCC(CC) American Board of Clinical Chemistry in clinical chemistry
ABCC(TC) American Board of Clinical Chemistry in toxicological chemistry
ABD American Board of Dermatology
ABFT American Board of Forensic Toxicology
ABIM(Hem) American Board of Internal Medicine in hematology
ABIM(Onc) American Board of Internal Medicine in medical oncology
ABMLI American Board of Medical Laboratory Immunology
ABMM American Board of Medical Microbiology
ABOMP American Board of Oral and Maxillofacial Pathology
ABP(AP) American Board of Pathology in anatomic pathology
ABP(BB/TM) American Board of Pathology in blood banking and transfusion medicine
ABP(CP) American Board of Pathology in clinical pathology
ABP(DP) American Board of Pathology in dermatopathology
ABP(MGP) American Board of Pathology in molecular genetic pathology
ABP(MMB) American Board of Pathology in medical microbiology
AOBP(LM) American Osteopathic Board of Pathology in laboratory medicine
AOBP(AP) American Osteopathic Board of Pathology in anatomic pathology
AOBP(DP) American Osteopathic Board of Pathology in dermatopathology
NRCC National Registry for Certified Chemists
DOH-238(I) (1/24) 1
4. QUALIFICATION FOR BOARD
Indicate the specific training and/or experience which qualified you to sit for board examination.
5. PHYSICIAN AND DENTIST LICENSURE

Physicians and dentists who are licensed and registered with the New York State Education Department must provide a copy of their
current license and registration. Applicants not licensed in New York State but in another state must provide a copy of their current
license in their state of practice.
6. EMPLOYMENT DURING THE PREVIOUS SIX YEARS

List all sites of employment within the previous six years.
7. CATEGORIES REQUESTED
Check each category you seek to hold on your certificate.
• Refer to the “Definition and Scope of CQ Categories” on our website (https://www.wadsworth.org/regulatory/clep/certificate-
requirements) to determine applicable categories.
• To direct clinical laboratory testing in any category in a facility under New York State laboratory permit, the director/assistant
director must hold the appropriate category on his/her/their Certificate of Qualification. Refer to the “Crosswalk of CQ Categories
and Permit Categories” on our website (https://www.wadsworth.org/regulatory/clep/certificate-requirements) for further
information.
• For a list of abbreviations for board certification, please see item 3 above, BOARD CERTIFICATION.
• ALL APPLICANTS MUST DEMONSTRATE EXPERIENCE OBTAINED WITHIN THE PREVIOUS SIX YEARS FOR EACH
CATEGORY REQUESTED.
o If you are applying for a category that has a qualifying board listed on page 1 and your entire residency and fellowship
occurred within the past six years, letters and/or Questionnaires documenting your training and/or experience within the
previous six years are not required unless experience is indicated as a requirement for the category (see Categories
Requested table on the application).
o If your residency and/or fellowship, or portions thereof, was completed more than six years prior to this application, one or
more letters and/or Questionnaires attesting to training and/or experience gained within the previous six years are required.
o For rotation subjects during a residency and/or fellowship that were completed more than six years prior to this application,
letters and/or Questionnaires documenting additional experience are required.
• As noted on Categories Requested table on the application, some categories recognize experience in lieu of board certification.
The applicant must demonstrate at least four years of postdoctoral training and/or experience in an acceptable laboratory, including
two years personally performing, supervising, and/or directing testing of human clinical specimens in each category sought and two
years of general laboratory management, or an equivalent combination of training and/or experience.
o Training and/or experience must be documented in the form of letters from, or Questionnaires signed by, laboratory directors
or supervisors under whom the training and/or experience was acquired. Letters must provide specific details about the
dates (month and year) and location of training and/or experience, including laboratory name, PFI/CLIA number,
address, and facility type (hospital, medical research, etc.). Letters must also include the number of specific
tests/analytes and procedures personally performed, supervised and/or directed, along with the specimen source(s),
methodology, and equipment for each, and whether each is an FDA- Approved assay or laboratory-developed test
(LDT). Letters from administrators or other responsible third parties are acceptable only if the applicant documents that
primary supervisors are not available.
8. CERTIFICATION
Respond to the questions by checking the appropriate answer. Sign and date the application.
Enclose a $40.00 application fee payment by check or money order made payable to “New York State Department of Health.”
Indicate the applicant’s name on the check or check stub. Submit the application form, a current curriculum vitae, and supporting
documentation along with the $40.00 application fee to:
For United States Postal Service: For express delivery:
Clinical Laboratory Evaluation Program Clinical Laboratory Evaluation Program

Biggs Lab – Wadsworth Center Biggs Lab – Wadsworth Center
NYS Department of Health NYS Department of Health
Empire State Plaza Dock J – P1, Empire State Plaza
Albany, NY 12237 Albany, NY 12237
DOH-238(I) (1/24) 2

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CLINICAL LABORATORY EVALUATION PROGRAM

ABBREVIATIONS FOR ACCEPTED BOARD CERTIFICATIONS:

ABB(HLCD) American Board of Bioanalysis as High Complexity Laboratory Director

5. PHYSICIAN AND DENTIST LICENSURE

6. EMPLOYMENT DURING THE PREVIOUS SIX YEARS

For United States Postal Service: For express delivery:

Clinical Laboratory Evaluation Program Clinical Laboratory Evaluation Program

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