Skills Checklist - Phlebotomy General

This Skills Checklist is a self-evaluation to assess your recent experience in various clinical settings focusing on the past 2 years.

0 = No Experience
1 = Some Experience
2 = Intermittent Experience
3 = Experienced
4 = Very Experienced

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AGE OF PATIENTS CARED FOR *

	0	1	2	3	4
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School Age Child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)

PATIENT IDENTIFICATION *

	0	1	2	3	4
Inpatient Identification
Infants and Young Children Identification
Emergency department Identification
Ambulatory Patient Identification

EQUIPMENT *

	0	1	2	3	4
Alcohol Swabs
Arterial Blood Gas Kit
Cotton Swabs
Occult Blood Packets
Heel Warmers
Infant Restraints
Laboratory Requisitions
Pin Worm Kits
Vacutainer Holders
VacutainerT
Blood Culture Bottles
Blood Culture Preparation kits
Centrifuge
24 Hour Urine Containers
Capillary Blood Kits
Bacteria Media
Drug Screen kits
Ova Parasite Containers
Legal Blood Draw Kits
Paternity Blood Draw Kits
RSV Kits
Glucola
Red Top Tubes (plain)
Light Blue Top Tubes (Coag, Sodium Citrate)
Serum Separator (SST, tiger top)
Green Top(Heparin, Lithium, NA+, ammonium)
Purple Top (EDTA)
Gray Top (NA+ Fluoride and K+ oxalate)
Brown Top (Lead)
Butterfly Needles
Other - Rate

GENERAL *

	0	1	2	3	4
Venipuncture Sites
Warming the Puncture site
Tourniquet Application & Removal
Decontamination of the Puncture Site
Blood-Borne Pathogens Exposure Control Plan
Tuberculosis Exposure Control Plan
PPE (Personal protective equipment)
Disposal of Contaminated items
Bio-hazard Waste Containers
Post Venipuncture Site Care
Order of Tube Collection
Skin Puncture Sites
Patient Positioning
Electronic Documentation

COMPLICATIONS/TROUBLESHOOTING *

	0	1	2	3	4
Fainting
Hematoma
Failure to Draw Blood
Petechiae
Excessive Bleeding
Mastectomy
Edema
Collapsed Veins
Hemolysis
Burned or Scarred Areas

TECHNIQUES *

	0	1	2	3	4
ABG Draws
Venipuncture
Heel Stick
Finger Stick
Microcapillary Skin Puncture
Other - Rate

TRANSPORT *

	0	1	2	3	4
Chilled Specimens
Warmed Specimens
Protection of Specimen from light
Microbiological Specimens

Position Category *

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Total Years of Experience *

First Name *

Last Name *

Social Security # *

Date of Birth *

Email *

Phone *

Attestation *

I certify that the information provided above accurately reflects education received and my experience in each of the clinical areas identified, particularly within the last 2 years. I hereby authorize Alliant Personnel Resources (The Company) to collect, store, and release any information that I have provided in this Skills Checklist and/or any other documentation and information they have collected or that I have submitted in any form to its parent company(s), its subsidiaries, or other subcontractors/its service providers as it deems necessary in its business operations as well as to individuals and companies in relation to consideration of employment as a Healthcare Professional with those companies and individuals. I acknowledge that The Company will take precaution and care to protect my personal information that is collected/stored/shared but cannot guarantee permanent data security and I release The Company from all related liability for damages or punitive liability.

Please verify that you are human *

Signature *

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