Phlebotomist Skills Checklist

Phlebotomist 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

Patient Care Settings*

	Proficiency	Frequency
ER Department
General Clinic Adult
General Laboratory
Geriatric Population
Health / Wellness Screening
HIV / Infection Unit
Hospital In-Patient
Hospital Out-Patient
ICU
Labor & Delivery
Med / Surg Unit
MRI
Neonate Population
Nuclear Medicine
Nursing Home
Occupational Health
Oncology Population
Oncology Unit
Orthopedic Unit
Pediatric Population
Specialty Clinic
Surgical Population

Patient Identification*

	Proficiency	Frequency
Inpatient Identification
Infants and Young Children Identification
Emergency Department Identification
Ambulatory Patient Identification

Equipment*

	Proficiency	Frequency
Arterial Blood Gas Kit
Occult Blood Packets
Infant Restraints
Laboratory Requisitions
Pin Worm Kits
Serum Separators
Centrifuge
Bacteria Media
Drug Screen Kits
Ova Parasite Containers
Legal Blood Draw Kits
Paternity Blood Draw Kits
Red Top Tubes (Plain)
Light Blue Top Tubes (Coag: Sodium Citrate)
Serum Separator (SST, Tiger Top, Speckle)
Green Top (Heparin, Lithium, NA+, Ammonium)
Purple Top (EDTA)
Gray Top (NA+ Fluoride and K+ Oxalate)
Brown Top (Lead)

Techniques and Skills*

	Proficiency	Frequency
Activated Blood Time
Blood Culture
Butterfly
Capillary Tube
Computer Entry
Fasting Glucose
Finger Stick
Gauged Needles
Heel Stick
Lancet
Microcapillary Skin Puncture
STAT Draws
Type & Cross match
Venipuncture Arm Site
Venipuncture Foot Site
Venipuncture Hand Site

General*

	Proficiency	Frequency
Tourniquet Application & Removal
Blood-Borne Pathogens Exposure Control Plan
Tuberculosis Exposure Control Plan
PPE (Personal Protective Equipment)
Disposal of Contaminated Items
Bio-Hazard Waste Containers
Order of Tube Collection
Patient Positioning

Complications / Troubleshooting*

	Proficiency	Frequency
Fainting
Hematoma
Failure to Draw Blood
Petechiae
Excessive Bleeding
Mastectomy
Edema
Collapsed Veins
Hemolysis
Burned or Scarred Areas

Transport*

	Proficiency	Frequency
Chilled Specimens
Warmed Specimens
Protection of Specimen From Light
Microbiological Specimens

Age Specific Criteria*

	Proficiency	Frequency
Newborn / Neonatal (up to 30 days)
Infant (30 days to 1 year)
Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School Age (5 to 12 years)
Adolescents (12 to 18 years)
Young Adults (18 to 39 years)
Middle Adults (40 to 64 years)
Older Adults (65 & up)

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*

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Hour MinutesAM/PM Option

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