MT (CLS) Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Inpatient Acute Care Facility	123
Trauma Center	123
Academic/Teaching Facility	123
Outpatient Care Facility	123
Long term care/Skilled Nursing	123
Clinic/Ambulatory	123
Home Health Setting	123

BLOOD BANK:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Component Preparation	123
Special Blood Typing	123
Procedures	123
Patient Identification	123
Emergency Release	123
Freezing Blood	123
Antibody Idenification	123
Antibody Titer	123
Blood Irradiation	123
Cold Agglutinins	123
Direct Coombs Test	123
Indirect Coombs Test	123
Cross Match	123
Donor Unit Collections	123
Immediate Spin Cross Match	123
Plasmapheresis	123
Plateletpheresis	123
Rhogam	123
Kell, Kidd, Duffy, RH HR, MNS, Lewis, P	123
Type RH	123

URINALYSIS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Automated Instrumentation	123
Crystal Identification	123
Semen Analysis	123
Macroscopic U.A.	123
Microscopic U.A.	123

HEMATOLOGY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Body Fluid Count	123
Bleeding Time	123
Lee-White Clotting Time	123
Differential	123
Eosinophil Count	123
Factor Assays	123
Fibrinogen	123
Fibrin Split Products/FDP	123
Platelet Aggregation	123
Platelet Count	123
PT and PTT	123
Reticulocyte	123
Sedimentation Rate	123
Sickle Cell Prep	123
PAS, Peroxidase, Leukocyte, Aldaline Phosphatase	123
Thrombin Time	123
Fetal Hemoglobin	123

CHEMISTRY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Acetone Analysis	123
Atomic Absorption	123
Thin Layer Chromatography	123
Gas Chromatography	123
CSF/Body Fluid Drug Monitoring	123
CSF/Body Fluid Electrolytes	123
Electrophoresis	123
Immunoelectrophoresis	123
Osmolality	123
Stool Analysis	123
Instrumentation Used - Blood Gas	123
Instrumentation Used - Main Chemistry Unit	123

IMMUNOLOGY/SEROLOGY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hemagglutination Inhibition	123
Pregnancy Testing	123
Meningitis Screen	123
Body Fluids	123
Rubella Serology	123
ANA	123
ASO Titer	123
C3, C4, Total Complement	123
Febrile Agglutinations	123
FTA-ABS	123
LE Cell Prep	123
Monostat	123
Radial Immuno Diffusion	123
Rheumatoid Factor	123
RPR	123
TORCH Studies	123

PHLEBOTOMY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Basic Safety Guidelines: gloves and goggles	123
Communication Skills	123
Ability to Write Procedures	123
Masks	123
Use of Balance (weighing)	123
Anticoagulants - Knowledge of Tube Types and Uses	123
Calculation for Solution Prep: molarity and molality	123
Finger Stick	123
Heel Stick	123
MLA	123
Operation of Centrifuge	123
Pediatric	123
Pipetting	123
To Contain	123
To Deliver	123
Venipuncture	123
Volumetric	123

MICROBIOLOGY/VIROLOGY:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Blood Culture	123
Cell Culture	123
Aerobic Culture	123
Anaerobic Culture	123
Anaerobic Identification	123
Mycobacteria: Culture	123
Sensitivities	123
Virus Identification	123
Virus Isolation	123
Acid Fast Stain (Fluorescent)	123
Acid Fast Stain (Kinyoun)	123
C Difficili Assay	123
Concentration Techniques	123
Culture Plating	123
Darkfield	123
Gram Stain	123
Identification	123
India Ink	123
KOH Prep	123
M.I.C.	123
Chlamydia Culture	123
Chlamydia Smear	123
Malarial Examination	123
Occult Blood	123
Organism Identification (Aerobic)	123
Ova and Parasite Concentration	123
Ova and Parasite Identification: Trichone	123
West Mount - Mobility	123
Wet Mount	123

RIA:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Data Reduction	123
Curves/Regression	123
Counters	123
Background Counts	123
Scintillation Counter	123
Hormone Testing	123
Radiation Safety Techniques	123
Instrumentation/Gamma Counters	123
B12/Folates	123
Hepatitis	123
Thyroid Testing	123
Tumor Markers	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *