Organization Profile Form

Registered Phlebotomy Technician (RPT) AMT
Organization Profile
Organization Name*
Campus Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
School Type*

High SchoolCommunity CollegeCareer SchoolTechnicalUniversityApprenticeshipWorkforce Development
Accreditor*

NAACLSNot AccreditedOther
High School Affiliate*
Name of Partnered Organization
Program is:

Registered with the US Department of Labor (DOL)A federally recognized State Apprenticeship Agency (SAA)Other
Workforce Development Affiliate
Current certification agency used (check all that apply)*

AMTASCPASPTNCCTNHANoneOther
Professional Website Address and/or Academic Program Links*
example: www.amt-university.org
Contact Info
Contact Name*

First NameLast name
Title*
Business Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Program Curriculum

As indicated in your organization's course catalog
Number of Classroom Clock Hours:*
(Convert credit hours to clock hours)
Number of Externship Clock Hours*
(Convert credit hours to clock hours)
Total Program Hours
Length of Program*
(Length of time it takes for students to complete the program)
Length of Program*
Is the phlebotomy program embedded in or part of another program?*

YesNo
The phlebotomy program is embedded in (select the program type):*

Medical AssistantMedical Laboratory AssistantMedical Laboratory TechnicianMedical Laboratory ScienceOther
Do the students complete 50 venipunctures and 10 capillary punctures from human sources as part of their training?*

YesNo
Attach a copy of your syllabus or course outline*

Cancelof
Additional Questions for International Programs
How long has your program been in existence?*
Is your program accredited or recognized by any accrediting body?*

YesNo
Name of Accreditation*
The average number of students you graduate per year?*
What is the placement rate (% of students) placed in jobs that pertain to their field of study?*
% of Students
Do students take any third-party exam (not issued by the school)?*

YesNo
What is the average pass/rate for that third-party exam?*
What are the qualifications of the main faculty responsible for teaching this program?*
Minimum Program Requirements

Check all areas below which apply to your curriculum
Obtain Blood Samples:

Proper patient identificationPhysiological aspects of blood collectionPrepare patient/select proper venipuncture sitesUse of proper tube drawPerform venipuncture and capillary puncturesHeel punctures on infantsProvide proper post careMaintain specimen integrityFollow transfusion services protocols
Specimen Collection and Processing:

Proper handling to maintain integrityTime/Temp requirementsProper station for deliveryProcess for shippingInstruct patient in urine/other specimen collection requirementsCollection/POCT specimens
Professional Communication:

Develop/use proper and professional communication skillsProper telephone technique and etiquetteInform patients of special test requirements
Terminology, Anatomy and Physiology:

Basic terminology, including suffixes, prefixes and root wordsBasic physiological symptomsBasic anatomy
Time Management/ Assignment Organization:

Read orders/ requisitionsSet priorities for collectionSchedule time intervals for tolerance testSchedule time intervals for drug-dependent testsRefer problems to supervisors appropriatelyCooperate with coworkers in the completion of assignments
Clerical Skills/Duties:

Chart/file laboratory reportsMaintain inventory levels/ order and restock suppliesEnter/retrieve/verify patient collection data and special notations using appropriate sources
Safety Standards/ Procedures:

Identify appropriate regulatory and standard setting agenciesMaterial safety data sheets (MSDS) useEmploy universal/ standard precautionsEmploy infection control and isolation techniquesRecognize patient problems related to syncope, nausea, etc.
Legal, Ethical and Professional Considerations:

Principals of liability regarding phlebotomy practicesEmploy professional conduct and appearancePerform duties professionally, ethically, and legally, adhering to criminal justice and civil rights acts
Total Program Requirements Selected
Decimal of Program Requirements Selected
% of Program Requirements Selected
By submitting this form, I am attesting to the accuracy of the information provided.
Agreement*
Please verify that you are human*
N/A - Current certification agency used
(if other)
N/A - Is the phlebotomy program part of the medical assisting program?

YesNo
N/A - Is the phlebotomy program part of the medical laboratory technician program?

YesNo
N/A - Is the phlebotomy program part of the medical laboratory science program?

YesNo
N/A - Is the phlebotomy program part of the medical laboratory assisting program?

YesNo
N/A - Program is:

Registered with the US Department of Labor (DOL)A federally recognized State Apprenticeship Agency (SAA)
N/A - Workforce Development Affiliate
Name of Partnered Organization
N/A - Is your program accredited or recognized by any accrediting body?

YesNo
N/A - syllabus or course outline*

Cancelof
Account Care
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Registered Phlebotomy Technician (RPT) AMT

Organization Profile

Contact Info

Program Curriculum

Additional Questions for International Programs

Minimum Program Requirements