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Clinical Lab - Application As Head of Lab

The document is an application for the position of head of a clinical laboratory. It requests information including the applicant's name, contact details, education and training history, and previous experience supervising clinical laboratories. The applicant certifies that the information provided is true and agrees to operate the laboratory in accordance with relevant laws and regulations.

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Jose Mari F. Esguerra
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301 views1 page

Clinical Lab - Application As Head of Lab

The document is an application for the position of head of a clinical laboratory. It requests information including the applicant's name, contact details, education and training history, and previous experience supervising clinical laboratories. The applicant certifies that the information provided is true and agrees to operate the laboratory in accordance with relevant laws and regulations.

Uploaded by

Jose Mari F. Esguerra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION AS HEAD OF CLINICAL LABORATORY

The Director
Health Facilities and Services Regulatory Bureau/DOH-Regional Office
Department of Health

Sir,

In compliance with the requirements of Republic Act (RA) No. 4688 and
Administrative Order (AO) No. 2007-0027, I have the honor to apply as head of:

_________________________________________
Name of Clinical Laboratory
_________________________________________
Address of Clinical Laboratory

I. Name of Applicant: ____________________________________________


Landline No.: __________________Mobile No.: ____________________
Address: ____________________________________________________

II. Education and Training (Use additional sheets if necessary):


Medical School/Institution ____________________________________
Inclusive Dates/Year Graduated _______________________________

Specialty Board Date Certified Training Institution


PBP1 Anatomic Pathology
PBP Clinical Pathology
PBP Anatomic and Clinical
Pathology
Others: Specify_________

III. List all clinical laboratories/ HIV-testing laboratory/ blood bank supervised/
headed or associated with:

Name and Address of Clinical Working Time Work Schedule


Laboratory
A. As Head
B. As Associate

I hereby certify that the foregoing statements are true. I assume full responsibility
that the operation of the clinical laboratory is in accordance with the Rules and
Regulations pursuant to RA 4688 and AO No. 2007-0027.

______________________________
Signature over Printed Name
_____________
Date

1
PBP – Philippine Board of Pathology
Form-CL-Head-A
Revision: 01
12/03/2014

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