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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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