Organization Profile Form

Registered Phlebotomy Technician (RPT) AMT
Please note: Programs must be active and currently enrolling, instructing, or graduating students at the time organizational profile information is submitted for AMT review. AMT is unable to review or approve inactive, discontinued, or planned programs that are not yet operational.
Organization Profile
Organization Name
Campus Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
School Type
Accreditor

Other
High School Affiliate
Name of Partnered Organization
Program is:

Other
Workforce Development Affiliate
Current certification agency used (check all that apply)

Other
Professional Website Address and/or Academic Program Links
example: www.amt-university.org
Contact Info
Contact Name

First NameLast name
Title
Business Email
example@example.com
Phone Number
Format: (000) 000-0000.
Program Curriculum

As indicated in your organization's course catalog
Number of Classroom Clock Hours:
(Convert credit hours to clock hours)
Number of Externship Clock Hours
(Convert credit hours to clock hours)
Total Program Hours
Length of Program
(Length of time it takes for students to complete the program)
Length of Program
Is the phlebotomy program embedded in or part of another program?
The phlebotomy program is embedded in (select the program type):

Other
Do the students complete 50 venipunctures and 10 capillary punctures from human sources as part of their training?
Attach a copy of your syllabus or course outline

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Additional Questions for International Programs
How long has your program been in existence?
Is your program accredited or recognized by any accrediting body?
Name of Accreditation
The average number of students you graduate per year?
What is the placement rate (% of students) placed in jobs that pertain to their field of study?
% of Students
Do students take any third-party exam (not issued by the school)?
What is the average pass/rate for that third-party exam?
What are the qualifications of the main faculty responsible for teaching this program?
Minimum Program Requirements

Check all areas below which apply to your curriculum
Obtain Blood Samples:
Specimen Collection and Processing:
Professional Communication:
Terminology, Anatomy and Physiology:
Time Management/ Assignment Organization:
Clerical Skills/Duties:
Safety Standards/ Procedures:
Legal, Ethical and Professional Considerations:
Total Program Requirements Selected
Decimal of Program Requirements Selected
% of Program Requirements Selected
By submitting this form, I am attesting to the accuracy of the information provided.
Agreement
Please verify that you are human
N/A - Current certification agency used
(if other)
N/A - Is the phlebotomy program part of the medical assisting program?
N/A - Is the phlebotomy program part of the medical laboratory technician program?
N/A - Is the phlebotomy program part of the medical laboratory science program?
N/A - Is the phlebotomy program part of the medical laboratory assisting program?
N/A - Program is:
N/A - Workforce Development Affiliate
Name of Partnered Organization
N/A - Is your program accredited or recognized by any accrediting body?
N/A - syllabus or course outline

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Account Care
Should be Empty:

Registered Phlebotomy Technician (RPT) AMT

Organization Profile

Contact Info

Program Curriculum

Additional Questions for International Programs

Minimum Program Requirements