Medical Laboratory Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyMedical LaboratoryBlood bank 1 2 3 4 Chem 1 2 3 4 Hemo 1 2 3 4 Micro 1 2 3 4 Serol 1 2 3 4 ProcedurePatient positioning 1 2 3 4 Fingerstick 1 2 3 4 Venipuncture 1 2 3 4 Warming the puncture site 1 2 3 4 Tourniquet application & removal 1 2 3 4 Decontamination of the puncture site 1 2 3 4 Tuberculosis exposure control plan 1 2 3 4 Post venipuncture site care 1 2 3 4 Order of tube collection 1 2 3 4 EquipmentArterial blood gas kits 1 2 3 4 Occult blood packets 1 2 3 4 Heel warmers 1 2 3 4 Pin worm kits 1 2 3 4 Serum separators 1 2 3 4 Blood culture preparation kits 1 2 3 4 Centrifuge 1 2 3 4 Capillary blood kits 1 2 3 4 Bacteria media 1 2 3 4 Drug screen kits 1 2 3 4 Ova parasite containers 1 2 3 4 Legal blood draw kits 1 2 3 4 Paternity blood draw kits 1 2 3 4 RSV kits 1 2 3 4 ChemistryAcetone analysis 1 2 3 4 Atomic absorption 1 2 3 4 B12/folates 1 2 3 4 CSF protein 1 2 3 4 Drug monitoring 1 2 3 4 Electrolytes 1 2 3 4 Electrophoresis 1 2 3 4 Gas chromatography 1 2 3 4 Hepatitis 1 2 3 4 Hormone testing 1 2 3 4 Immunoelectrophoresis 1 2 3 4 Include blood gas 1 2 3 4 Main chemistry unit 1 2 3 4 Osmolality 1 2 3 4 Stool analysis (fecal fats) 1 2 3 4 Thin layer chromatography 1 2 3 4 Thyroid testing 1 2 3 4 Tumor markers 1 2 3 4 RIABackground counts 1 2 3 4 Counters 1 2 3 4 Curves/regressions 1 2 3 4 Data reduction 1 2 3 4 Instrumentation/gamma 1 2 3 4 Radiation safety techniques 1 2 3 4 Scintillation counter 1 2 3 4 Blood BankAntibody identification 1 2 3 4 Antibody titer 1 2 3 4 Blood irradiation 1 2 3 4 Component preparation 1 2 3 4 Coombs Test:Direct 1 2 3 4 Indirect 1 2 3 4 Cross match 1 2 3 4 Donor unit collections 1 2 3 4 Emergency release 1 2 3 4 Freezing blood 1 2 3 4 Immediate spin cross match 1 2 3 4 Patient identification 1 2 3 4 Plasmapheresis 1 2 3 4 Plateletpheresis 1 2 3 4 Procedures 1 2 3 4 Rhogam 1 2 3 4 Antigen typing 1 2 3 4 Type, RH 1 2 3 4 Microbiology/VirologyConcentration techniques 1 2 3 4 Identifi cation 1 2 3 4 Acid fast stain (fl uorescent) 1 2 3 4 Acid fast stain (kinyoun) 1 2 3 4 Anaerobic culture 1 2 3 4 Anaerobic identification 1 2 3 4 Blood culture 1 2 3 4 C. difficile assay 1 2 3 4 Cell culture technique (viral) 1 2 3 4 Chlamydia culture 1 2 3 4 Chlamydia smear 1 2 3 4 Culture plating 1 2 3 4 Darkfield 1 2 3 4 Gram stain 1 2 3 4 India ink 1 2 3 4 KOH prep 1 2 3 4 Malarial examination 1 2 3 4 Myobacteria culture 1 2 3 4 Occult blood 1 2 3 4 Organism identification 1 2 3 4 Ova & parasite concentration 1 2 3 4 Trichcone 1 2 3 4 Wet mount 1 2 3 4 SensitivesK.B. 1 2 3 4 M.I.C. 1 2 3 4 Virus isolation 1 2 3 4 Wet mount-motility 1 2 3 4 UrinalysisAutomated instrumentation 1 2 3 4 Large volume automation equipment 1 2 3 4 Small volume automation equipment 1 2 3 4 Crystal identification 1 2 3 4 Macroscopic U.A 1 2 3 4 Microscopic U.A 1 2 3 4 Semen analysis 1 2 3 4 HematologyBleeding time 1 2 3 4 Body fluid count 1 2 3 4 CBC 1 2 3 4 D-dimer 1 2 3 4 Differential 1 2 3 4 Eosinophil count 1 2 3 4 Factor assays 1 2 3 4 Fetal hemoglobin 1 2 3 4 Fibrin split products/FDP 1 2 3 4 Fibrinogen 1 2 3 4 Lee-White clotting time 1 2 3 4 Platelet aggregation 1 2 3 4 Platelet count 1 2 3 4 PT & PTT 1 2 3 4 Reticulocyte count 1 2 3 4 Sedimentation rate 1 2 3 4 Special stains (PAS, peroxidase, leukocyte alkalinephosphatase) 1 2 3 4 Sickle cell prep 1 2 3 4 Thrombin time 1 2 3 4 Serology / ImmunologyANA 1 2 3 4 ASO titer 1 2 3 4 C3, C4, total complement 1 2 3 4 Cold agglutinins 1 2 3 4 C-reactive protein 1 2 3 4 ELISA testing 1 2 3 4 Febrile agglutinations 1 2 3 4 Fluorescent testing 1 2 3 4 FTA-ABS 1 2 3 4 Hemagglutination inhibition 1 2 3 4 LE cell prep 1 2 3 4 Monospot 1 2 3 4 Pregnancy testing 1 2 3 4 Radial immuno diffusion 1 2 3 4 Rheumatoid factor 1 2 3 4 RPR 1 2 3 4 Rubella serology 1 2 3 4 TORCH studies 1 2 3 4 National Patient Safety GoalsAccurate patient identification 1 2 3 4 Labeling 1 2 3 4 Effective communication 1 2 3 4 Infection control 1 2 3 4 Quality control/quality assurance 1 2 3 4 Assist with On-site procedure 1 2 3 4 Age Specific CompetenciesNewborn / neonate (Birth-30 days) 1 2 3 4 Infant (31 days-1 year) 1 2 3 4 Toddler (2-3 years) 1 2 3 4 Preschool (ages 4-5 years) 1 2 3 4 School Age (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adult (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adult (ages 65-79 years) 1 2 3 4 Elderly (80+ years) 1 2 3 4 Additional Skills & TrainingPlease list any additional skills & trainingAuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Medical Laboratory Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
