CYNET_SYSTEMS_MAIN_LOGO.gif   MEDICAL LABORATORY TECHNICIAN MEDICAL TECHNOLOGIST PHLEBOTOMIST SKILLS CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) WORK SETTINGS 1 2 3 4  
Free Standing Lab  
Reference Lab  
Acute Setting  
Rating Stars (Click) BLOOD BANK 1 2 3 4  
Patient Identification Process  
ABO/Rh/Antibody Screen & ID  
Crossmatch - Immediate Spin/IgG  
Antigen Typing  
Antibody Typing: Gel Method  
Antibody Typing: Tub Method  
Cold Agglutinins  
Rhogam Screening  
Cord Blood Evaluation  
Thawing/Cooling of Blood Products  
Donor Collection Procedures  
Issue Blood Product to Pt. Care Area  
Emergency Release  
Transfusion Reaction Workup  
Instrumentation (Specify)  
Instrumentation (Specify)  
Rating Stars (Click) CHEMISTRY 1 2 3 4  
Specimen Preparation  
Acetone Analysis  
Arterial Blood Gas  
B -12 Folates  
Cardiac Enzymes  
Chromatography - Gas  
Chromatography - Thin Layer  
Electropheresis  
Hormone/Thyroid  
Immunoassay  
Osmolality  
Stool Analysis  
Therapeutic Drug Monitoring  
Tumor Markers  
Analyzer Use/Troubleshooting  
Review & Interpretation of QC  
Instrumentation (Specify)  
Instrumentation (Specify)  
Rating Stars (Click) HEMATOLOGY/COAGULATION 1 2 3 4  
Automated Instrument Use  
CBC Manual  
Differential Manual  
Sed Rate Manual  
Reticulocyte Count  
Fetal Hemoglobin  
RBC Morphology  
Platelet Count  
Platelet Morphology  
Body Fluid Analysis  
Special Stains - e.g. PAS, LAP, Peroxidase  
PT/PTT/INR  
D-Dimer  
Fibrinogen  
Factor Assays  
Fibrin Degradation Products  
Thrombin Time  
Platelet Function Analysis  
Instrumentation (Specify)  
Instrumentation (Specify)  
Rating Stars (Click) IMMUNOLOGY/SEROLOGY 1 2 3 4  
RPR/RPR Titer  
Rheumatoid Titer  
ANA  
LE Prep  
HIV Rapid  
HIV Antibody Detection  
Rubella  
CMV  
Instrumentation (Specify)  
Instrumentation (Specify)  
Rating Stars (Click) MICROBIOLOGY 1 2 3 4  
Cultures  
Sub Cultures  
Sensitivities  
Kit Testing - Monospot/ASO Titer  
Kit Testing - Flu/Rapid Strep/RSV  
Wet Prep/KOH Prep  
AFB Stain/Culture  
O&P  
Chlamydia  
Processing Specimens for Viral/Fungal Cultures  
Vitek  
Instrumentation (Specify)  
Instrumentation (Specify)  
Rating Stars (Click) URINALYSIS 1 2 3 4  
Crystal Identification  
Macroscopic Analysis  
Microscopic Analysis  
Pregnancy Testing  
Instrumentation (Specify)  
Instrumentation (Specify)  
Rating Stars (Click) PHLEBOTOMY 1 2 3 4  
Patient Identification  
PPE Equipment (Gloves/Mask, etc.)  
Adult Venipuncture  
Pediatric Venipuncture  
Dermal Stick (Finger/Heel)  
Butterfly Draw  
Arterial Draw  
Tube Types and Usage  
Centrifuge Operation  
Bleeding Time  
Blood Culture Collection  
Blood Alcohol Collection  
Drug Screening Collection  
Rating Stars (Click) GENERAL EQUIPMENT 1 2 3 4  
Beckman  
Hitachi  
Ortho Vitros  
Roche  
Other: Specify  
Other: Specify  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) AGE APPROPRIATE CARE 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)  
Rating Stars (Click) LAB INFORMATION SYSTEMS 1 2 3 4  
Meditech  
Cerner  
Horizon  
Sunquest  
Orchard  
Other: Specify  
Other: Specify