Med Lab

2022

PROFESS I ONAL L I CENSURE & STATE AUTHOR I ZAT I ON D I SCLOSURE DETERMI NAT I ONS

MED I CAL LABORATORY TECHNOLOGY MS DE L TA COMMUN I TY COL L EGE

National Professional Licensure Disclosure Template Mississippi Community College Board

Use this form to denote each of the states and territories for which the national licensure examination (i.e. nursing) leads to professional licensure. For any states and/or territories not selected, an individual State Professional Licensure Disclosure Template will need to be completed.

Program CIP CIP Number

Leads to Licensure

Leads to Licensure

Leads to Licensure

State/Territory

State/Territory

State/Territory

Alabama

Kentucky Louisiana

Ohio

Alaska

Oklahoma

American Samoa

Maine

Oregon

Arizona Arkansas California Colorado

Maryland

Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota

Massachusetts

Michigan Minnesota Mississippi Missouri Montana Nebraska

Connecticut Delaware

Tennessee

District of Columbia

Texas

Florida Georgia Guam Hawaii Idaho Illinois Indiana

U.S. Virgin Islands

Nevada

Utah

New Hampshire

Vermont Virginia

New Jersey New Mexico

Washington West Virginia

New York

North Carolina North Dakota

Wisconsin Wyoming

Iowa

Kansas

Northern Mariana Islands

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments

State Professional Licensure DisclosureTemplate Mississippi Community College Board Use this form to document all evidence of reasonable efforts when determining whether a program will meet state professional licensure requirements.

Program

CIP Title CIP Number

Has Not Made a Determination

State/Territory

DoesMeet

Does Not Meet

Reasonable Efforts Made

Licensing Board Information Board Name Address City, State, and Zip Phone Number Website Reviewer Information

Name Email College Date of Review Reviewer Comments