Verification
of Qualifications
This
form is to verify that __________________________________ has satisfied the
following qualifications to be accepted to
Ø
At
least one (1) year or the equivalent of one year of Phlebotomy experience
Ø
At
least one-hundred successful venipunctures
It
is important to the student’s course success to have satisfied these
qualifications by the completion of the course.
Please
fill out items below and sign to verify.
Type of facility:
___Hospital
___HMO
___Physicians office
___Clinic
___Other (specify)__________________________
Student’s term of employment:
From_____________To______________________
Student’s daily workload
(venipunctures per day)
_______________
I
verify that the above information is correct to the best of my knowledge.
Signature________________________________________________
Your
Name______________________________________________
Title____________________________________________________
Address_________________________________________________
Email___________________________________________________
Telephone_________________________Fax___________________
Closest
VCCS facility, Community College or University
_______________________________________________________
Please
complete and mail or fax to:
Karen Gordon, Program Manager-MDL
Programs
Northern Virginia Community
College-Medical Education Campus Rm 228-B
703-822-6551 Fax 703-822-6614