"SELF EVALUATION"
MEDICAL TECHNOLOGY
SKILLS PROFICIENCY CHECKLIST

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     Last Name: 
    First Name: 
Middle Initial: 
        E-mail:
  
MT Years Experience:  
MLT Years Experience:

DIRECTIONS: Select the box that best describes your level of proficiency in each of the skills presented.

LEVELS OF PROFICIENCY KEY:

HP = Highly proficient; Extensively experienced; Able to supervise and/or train others.   SE = Some Experience;
Need review and assistance or supervision.
VE = Very Experienced; Can perform well, without assistance or supervision.   NE = No Experience
EX = Experienced; Competent;
Can perform independently;
May need initial review or supervision.
      
SKILL PROFICIENCY LEVEL SKILL PROFICIENCY LEVEL
HEMATOLOGY: HP VE EX SE NE   HP VE EX SE NE
CBC Fibrin Split Products/FDP
Differential Platelet Aggregation
Reticulocyte Count Lee-White Clotting Time
Platelet Count Fetal Hemoglobin
Sickle Cell Prep Body Fluid Count
Eosinophil Count Special Stains (PAS, Peroxidase Leukocyte Alkaline, Phosphatase)
Sedimentation Rate Automated Instrumentation:          
Bleeding Time (1)
PT & PTT (2)
Fibrinogen (3)
Factor Assays (4)
Thrombin Time            
SEROLOGY/ IMMUNOLOGY: HP VE EX SE NE   HP VE EX SE NE
RPR Radial Immuno Diffusion
FTA-ABS Hemagglutination Inhibition
ANA Rubella Serology
LE Cell Prep TORCH Studies
C3, C4 Total Complement Febrile Agglutinations
Rheumatoid Factor Instrumentation Used:          
Monospot (1)
Pregnancy Testing (2)
ASO Titer (3)
CHEMISTRY: HP VE EX SE NE   HP VE EX SE NE
Acetone Analysis Stool Analysis
Osmolality Fecal Fats
CSF Protein Instrumentation Used:          
Electrophoresis (1) Include Blood Gas
Immunoelectrophoresis (2) Drug Monitoring
Atomic Absorption (3) Main Chemistry Unit
Thin Layer Chromatography (4) Electrolytes
Gas Chromatography  Other:

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