HealthcareSeptember 25, 20269 min read

How to Become a Surgical First Assistant in 2026: CST to CSFA

The full route to working as a surgical first assistant, in order: program, NBSTSA CSFA exam, state licence and renewal, with timings and what each step costs you.

  • $66,800Median pay
  • +6%Job growth
  • Certificate or associate'sTraining
  • NBSTSA CSFAExam
  • $350Exam fee
How to become a surgical first assistant: step-by-step route 2026

Table of Contents

The route, start to finish

Becoming a surgical first assistant is a fixed sequence: an approved program, the NBSTSA CSFA exam, then whatever your state requires on top. Here is every stop in order, with realistic timings.

  1. 1

    Build a surgical or clinical foundation

    Surgical assisting programs set their own admission prerequisites. BLS notes that some surgical assistants start as surgical technologists and move into first assisting. Holding a CST alone does not qualify you for the CSFA exam.

  2. 2

    Complete a CAAHEP-accredited surgical assisting program

    Finish a surgical first assistant program accredited by CAAHEP (reviewed by ARC/STSA). Completing this program is the only first-time route to the CSFA exam.

  3. 3

    Apply to NBSTSA

    2-4 weeks for the ATT

    Apply online through the NBSTSA portal (Learning Builder) and pay $240 as an AST member or $350 as a non-member. Processing takes 2-4 weeks, or 3-5 business days with the $85 rush fee.

  4. 4

    Schedule and take the exam

    4-hour exam

    Schedule with PSI using your Authorization to Test email, or test on campus with your class. The exam has 175 multiple-choice questions (150 scored) in 4 hours. You pass by answering 99 scored questions correctly.

  5. 5

    Get a state license or registration if your state requires one

    Texas, Virginia, Illinois, Kentucky and Colorado all regulate surgical assistants in some form. Texas, for example, requires an associate's degree, a surgical assistant program transcript, a passed national exam, a current NBSTSA/ABSA/NSAA certificate, and 2,000 documented hours as a surgical assistant.

  6. 6

    Renew every two years

    Every 2 years

    Earn 38 AST-approved CE credits (8 of them live) in each 2-year cycle, submit them to AST, then renew with NBSTSA for $45.

Step one: the right program

The program is the one step you cannot shortcut. The exam body checks where you trained before it lets you sit, so an unaccredited course can cost you the whole route.

Program: Surgical assisting (surgical first assistant) program. Under the CAAHEP standards the sponsoring institution must award at least a certificate on completion; hospitals, medical centers and the Armed Forces can also sponsor programs.
Accreditation: CAAHEP, on the recommendation of ARC/STSA (Accreditation Review Council on Education in Surgical Technology and Surgical Assisting). Only CAAHEP accreditation qualifies for the CSFA exam.
Typical length: Certificate or associate's

Who is eligible to sit the exam

RouteWhat you need
Graduate of a CAAHEP-accredited surgical first assistant programGraduate from a surgical first assistant (surgical assisting) program accredited by CAAHEP, with proof of graduation (diploma, transcript, or signed letter on school letterhead from the program director or registrar). Students can apply before graduating, but must submit proof of graduation within 60 days of the exam date or their results are invalidated.
Current or previously certified CSFAEvidence of current or previous CSFA certification. This route is for recertification or reinstatement by exam, not for first-time candidates.

The exam itself

This is the checkpoint the whole route builds towards. The essentials:

Exam: NBSTSA National Certifying Examination for the Certified Surgical First Assistant (CSFA)
Questions: 175 (150 scored)
Time: 240 minutes
Where you test: Computer-based at PSI testing centers nationwide, by appointment Monday-Saturday (9 a.m. and 1:30 p.m. sessions); students can also test on campus through their program (web-based testing, WBT). A military base education center can give a web-based exam if the post is more than 100 miles from a test center. NBSTSA does not list live remote proctoring for the CSFA.
Passing standard: Criterion-referenced raw cut score set by NBSTSA standard setting: you pass by answering 99 of the 150 scored questions correctly (about 66%), per the NBSTSA CSFA certification page. Pretest items do not count.
Fee: $350

We broke the exam down domain by domain, with the weight of each and what its questions ask, in the NBSTSA CSFA content outline.

Licensure: what your state adds

The CSFA is a national certification, not a license, but several states regulate surgical assistants and accept it as their credential. Texas requires a Texas Medical Board surgical assistant license, which calls for an associate's degree, a surgical assistant program transcript, a passed exam and current certificate from NBSTSA, ABSA or NSAA, and 2,000 documented hours. Virginia requires a Board of Medicine surgical assistant license based on a current NBSTSA or NCCSA credential. Illinois registers surgical assistants through IDFPR and the title 'registered surgical assistant' is protected; registration requires a current CSFA, CSA (NCCSA) or SA-C (ABSA). Kentucky requires certification by the Board of Medical Licensure to practice as a surgical assistant, with exemptions such as nurses, PAs, and hospital employees working under direct RN supervision. Colorado requires registration with DORA's Division of Professions and Occupations before anyone performs surgical assistant duties. Other states have no specific surgical assistant credential, so hospital credentialing and employer policy decide.

StateWhat it requires
TXTexas Medical Board license (Licensed Surgical Assistant). Application (01.2026 version) requires: at least an associate's degree; a certified transcript from a surgical assistant program, medical school, RN first assistant program or surgical PA program; verification of a passed surgical assistant exam; a current certificate from ABSA, NBSTSA or NSAA; and a Work Experience form documenting 2,000 hours of full-time active work as a surgical assistant, with physician performance evaluations. Renewal: 36 CE hours every 24 months (at least half formal Category I, including 2 hours of ethics/professional responsibility) plus HHSC-approved human trafficking training.
VABoard of Medicine surgical assistant license (18VAC85-160-50). Qualifies with a current surgical assistant/surgical first assistant credential from NBSTSA or NCCSA, completion of an Armed Forces surgical assistant program, or (grandfather route) practice in Virginia in the six months before July 1, 2020. At renewal, credential-based licensees attest that the NBSTSA/NCCSA credential is still current.
ILIDFPR registration under the Registered Surgical Assistant and Registered Surgical Technologist Title Protection Act (title protection; practice under direct supervision of the operating physician, podiatrist or dentist). Requires graduation from an approved program (programs meeting NCCSA, NBSTSA or ABSA eligibility rules count, as do US military programs), passing a national surgical assistant exam, and current CSA, CSFA or SA-C certification. Apply through IDFPR CORE.
KYKentucky Board of Medical Licensure certifies surgical assistants (KRS 311.864-311.890). Under KRS 311.866, you may not practice as a surgical assistant without certification, except as a student in an approved program, a federal employee, another licensed/certified health worker within scope, an RN/LPN, a certified PA, or a hospital employee under direct RN supervision. Application fee $50 (non-refundable).
COColorado requires registration with the DORA Division of Professions and Occupations (C.R.S. 12-310-104) before performing surgical assistant duties; practicing unregistered is a misdemeanor. Registrants report education, employers, and whether they hold national certification. Whether national certification is required for registration was not confirmed.

Pay and job outlook

The US Bureau of Labor Statistics files surgical first assistants under “Surgical Assistants (SOC 29-9093), reported in the BLS OOH 'Surgical Assistants and Technologists' profile; this median is for surgical assistants only, not surgical technologists (SOC 29-2055, $64,650)”. Median means half earn more and half less; pay moves a long way with state, setting and experience, so read this as a benchmark, not an offer.

$66,800Median pay (May 2025)
+6%Job growth 2025-35

Keeping the credential

Cycle: Every 2 years
Requirement: 38 AST-approved continuing education credits per 2-year cycle, including 8 live credits. CE must be earned within the cycle and submitted to AST for approval before you renew with NBSTSA. Extra credits do not roll over. As an alternative, you can recertify by passing the exam again. If you have all required CE, you can still renew 1-90 days after expiration with a late fee; otherwise you must retake the exam.
Fee: $45 renewal fee by CE. Late renewal (1-90 days after expiration) adds $100, for $145 total. Recertifying by exam costs $450 for AST members or $550 for non-members. AST charges a fee to process CE earned while you are not a member.

The exam is the step most people underprepare for

ExamCert AI has 1,188 CSFA practice questions with explanations, built around the same outline this page walks through. Work them by domain, find the weak area, and fix it before test day.

Practise CSFA on ExamCert AICSFA Exam Content Outline 2026

FAQ

Can a CST sit for the CSFA exam based on experience?

No. The current NBSTSA eligibility page and the 2025 CSFA Candidate Handbook list only one first-time route: graduation from a CAAHEP-accredited surgical first assistant program. The only other listed route is for people who are already, or were previously, CSFA certified.

Which states require a license or registration for surgical assistants?

Texas and Virginia license surgical assistants through their medical boards. Illinois registers them through IDFPR, Kentucky certifies them through the Board of Medical Licensure, and Colorado requires registration with DORA before performing surgical assistant duties. Texas, Virginia and Illinois accept the NBSTSA CSFA as a qualifying national credential, but each state has additional requirements, so check with its regulator.

How much do surgical first assistants make?

BLS reports a median annual wage of $66,800 for surgical assistants in May 2025, compared with $64,650 for surgical technologists. Employment of surgical assistants is projected to grow 6% from 2025 to 2035, from about 24,400 to 25,900 jobs.

How do you keep the CSFA credential active?

The CSFA renews every 2 years with 38 AST-approved CE credits, 8 of which must be live. You submit the credits to AST, then file the NBSTSA renewal with a $45 fee. If you miss the CE, you must recertify by exam, which costs $450 for AST members or $550 for non-members.

Sources

Figures on this page come from NBSTSA and the other primary sources below:

Checked September 25, 2026. Fees, outlines and eligibility rules change — confirm with NBSTSA before you book.