Cytology Skills Checklist

Cytology Skills Checklist

First Name*

Last Name*

Years of Experience*

E-mail*

example@example.com

ANSWER KEY

PROFICIENCY

1=Not Applicable 2=No Experience 3=Some Experience

4=Experienced 5=Very Experienced

FREQUENCY

1=Never Performed 2=Assisted Only 3=Rarely Performed

4=Occasionally Performed 5=Regularly Performed

Cytology Gyn*

	Proficiency	Frequency
Screen : # / day
Review: # / day

Non-Gyn*

	Proficiency	Frequency
Ascitic Fluid
Bronchial
Esophageal
Gastric
Spinal
Urine

Thin-Prep*

	Proficiency	Frequency
GYN
Non-GYN
Preventative Maintenance

Fixations*

	Proficiency	Frequency
Saccomanno
CytoLyt
Carbowax
95% Alcohol
Filter Prep

Fine Needle Aspirations*

	Proficiency	Frequency
Assist
Make Smears
Collection
Preliminary Diagnosis
Onsite Procedures
Staining

Special Stains / Organisms*

	Proficiency	Frequency
GMS
PAP
Iron

The information provided is true and to the best of my knowledge. I hereby authorize Summit Medical Staffing to present my Skills Checklist to facilities for the purpose of employment. Please Type Your Name in This Box to Electronically Sign this Form.*

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Date*

MonthDayYear

Hour MinutesAM/PM Option

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