Rapid Temps Self Evaluation - Medical Technology

Print this form and fax or mail:
Fax to: (505) 797-3822
Mail to: 5150 San Francisco RD NE, Albuquerque, NM 87109

NAME: _____________________________________
      Last            First            M.I.

- MT  Years Experience: _____
- MLT Years Experience: _____

DIRECTIONS: Place an X in 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:

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)

BLOOD BANK:	HP	VE	EX	SE	NE		HP	VE	EX	SE	NE
Patient ID procedures						Donor Unit Collections
Cross Match						Blood Irradiation
Immediate Spin Cross Match						Plasmaphoresis
Type, RH						Plateletphoresis
Antibody Titer						Emergency Release
Antibody Identification						Special Blood Typing:
Coombs Test						(Kell, Kidd, Duffy, RH-HR, MNS, Lewis, P)
* Direct						Automated Instrumentation:
* Indirect						(1)
Rhogram						(2)
Component Preparation						(3)
Freezing Blood						(4)
Cold Agglutinins						(5)

MICROBIOLOGY/ VIROLOGY:	HP	VE	EX	SE	NE		HP	VE	EX	SE	NE
Gram Stain						Ova and Parasite Identification
Acid Fast Stain (Kinyoun)						* Trichcone
Acid Fast Stain (Fluorescent)						* Wet Mount
India Ink						Myobacteria:
West Mount-Motility						* Culture
Darkfield						* Concentration Techniques
KOH Prep						* Identification
Culture Plating						Chlamydia Culture
Organism Identification						Chlamydia Smear
Sensitivities						Cell Culture Technique (Viral)
* K.B.						Virus Isolation
* M.I.C.						Virus Identification
Blood Culture						C Difficili Assay
Anaerobic Culture						Malarial Examination
Anaerobic Identification						Automated Instrumentation:
Occult Blood						(1)
Ova and Parasite Concentration						(2)

RIA:	HP	VE	EX	SE	NE		HP	VE	EX	SE	NE
Radiation Safety Techniques						Hepatitis
Background Counts						Instrumentation:
Data Reduction						* Gamma
Curves/Regressions						* Scintillation Counter
Thyroid Testing						Other RIA Testing:
Hormone Testing						(1)
Tumor Markers						(2)
B12/Folates						(3)

GENERAL:	HP	VE	EX	SE	NE		HP	VE	EX	SE	NE
Phlebotomy						Calculation for Solution Prep.
* Venipuncture						(Molarity, Molality)
* Fingerstick						Use of Balance (Weighing)
* Heel Stick						Basic Safety Guidelines
* Pediatric						(Gloves, Goggles, Masks)
Pipetting						Communications Skills with
* M.L.A.						Physicians and Nurses
* To Deliver						Ability to Write Procedures
* To Contain						Computer Systems Used:
* Volumetric						(1)
Operation of Centrifuge						(2)
Knowledge of Tube Types						(3)
and Uses (Anticoagulants)						(4)

Signature: ___________________________     Date: _________________