× The federal government has shut down due to the failures of the President and Congress to continue government funding. Millions of Californians receiving benefits from state programs may be impacted. For now, California’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) will continue to provide services and enroll eligible families as long as funding is available. No new federal funding to California WIC will be provided until the President and Congress take action. Families should continue to use their WIC benefits and attend their WIC appointments. This information is subject to change, so please monitor the California WIC website for updates.

Please be wary of potential highly partisan political messaging while visiting federal government websites for information related to the federal government shutdown.

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Laboratory Field Services

Forms


Download forms using the links below. Clicking a link will open another tab in your browser. You can also download by right-clicking the link and choosing "Save."


State Forms

 LAB 116  (PDF) ​- Laboratory Personnel Report
 LAB 144A  (PDF) ​- Laboratory Testing Declaration
 LAB 144B (PDF) ​- Application for Additional Testing Site
 LAB 167 (PDF) ​- Annual Test Volume
 LAB 182 (PDF) ​- Owner's Attestation
 LAB 183 (PDF) ​- Laboratory Director's Attestation
 LAB 193 (PDF) ​- Notification of Laboratory Change
 LAB 1513 (PDF)
​- Disclosure of Ownership and Control Interest Statement

​​​​Out-of-State Forms​

 LAB 116 OS (PDF)​ ​- OOS Laboratory Personnel Report​
 LAB 167 OS (PDF) - OOS Annual Test Vol​ume of California Specimens​
 LAB 168 OS (PDF) - OOS Laboratory Personnel Qualification

Federal Forms

CMS 116 (PDF)
​- CLIA Application for Certification  || Link: Quick Start Guide (PDF)
CMS 209 (PDF) ​- CLIA Laboratory Personnel Report

Related Links

Payment Request Sheet (PDF) ​- Mail-in payment request for an online application
​LAB 163 (PDF)
​- Complaint Information Form

Send to LFS

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​Email to:
LFScc@cdph.ca.gov

  • Subject line: Include any reference such as State ID, CLIA ID, application ID, and facility name.
  • Body of email: Include information such as type of application (initial, renewal, changes, etc.)
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​Upload Online:                     
Upload the completed and signed forms in your application. ​

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