PER-Participant Documents

National Sterile Compounding Training

Participant Documentation Submission
Participant Name

First NameLast Name
Participant E-mail - DO NOT PROVIDE EVALUATOR EMAIL

Confirmation Emailexample@example.com; TSHP & PER are not responsible for lack of contact if this is entered incorrectly.
Participant NABP eProfile ID#
Participant Type
Evaluator Name

First NameLast Name
Evaluator E-mail

Confirmation Emailexample@example.com; TSHP & PER are not responsible for lack of contact if this is entered incorrectly.

Supervised Practice Documentation

Use this form to provide detailed information on the hands-on practice of the participant in each of the skills and topics.

Practice Log

Rows	Date	Topic	Total Time (minutes)
Practice 1
Practice 2
Practice 3
Practice 4
Practice 5
Practice 6
Practice 7
Practice 8
Practice 9
Practice 10
Practice 11
Practice 12
Practice 13
Practice 14
Practice 15
Practice 16
Practice 17
Practice 18
Practice 19
Practice 20

Total Practice Time (Hours)
Hours
Total Practice Time (Minutes)
Minutes
I certify by my signature below that on Date* at Facility* that the participant First Name* Last Name* has been observed practicing the tasks as indicated above.
Evaluator Signature
Evaluator Name

First NameLast Name

Rows	Yes	N/A
Removed all jewelry and objects up to elbow (including rings)
Did not have cuts, sunburn, nail polish or false nails
Turned on water and adjusted temperature correctly
Avoided unnecessary splashing during washing process
Cleaned nails First using soap & nail pick under warm running water
Used plenty of antibacterial soap during cleaning process
Cleaned all four surfaces of each finger
Cleaned all surfaces of hands, wrist and arms up to the elbow using a circular motion for at least 30 seconds
Did not touch the sink, faucet or other objects which would contaminate the hands during the process
Rinsed hands holding them upright and allowing water to drip down to elbow
Rinsed all soap residue off hands and arms
Dried hands properly and did not contaminate hands in process
Did NOT turn off water until hands were completely dry
Turned water off with dry, sterile, lint-free, disposable towels
Did not touch the faucet while turning water off

Rows	Yes	N/A
Removed outer lab jacket, make-up, & jewelry before entering ante room
Applied non-shedding shoe covers over clean shoes properly
Non-shedding hair covered was placed over all hair
Non-shedding beard cover applied appropriately over face if needed
Applied non-shedding face cover or mask over face covering both nose and chin
Washed hands properly prior to beginning process
Made sure hands/forearms were completely dry before donning gown
Correctly donned appropriate size non-shedding disposable, enclosed neck gown
Gown sleeves long and fit snugly at the wrists
Gown zipped, snapped, or tied to assure front was closed
Prior to applying sterile gloves, antiseptic hand cleansing was performed using a waterless alcohol-based surgical hand scrub with persistent rubbing activity
Made sure hands and arms were completely dry before applying gloves
Correct size non-shedding, sterile, powder-free gloves applied in clean room
Sterile gloves were applied over the outer cuff of the gown without contamination
Sterile gloves were disinfected as needed with Sterile 70% isopropyl alcohol throughout the entire compounding procedure
Gown and garb were applied properly and removed in correct sequence

Rows	Yes	N/A
Did not wear jewelry, false nails, makeup, etc. inside the hood
Donned appropriate apparel as required by US 797
Washed hands & cleaned hood correctly before beginning compounding process
Correctly performed all required calculations before entering clean room
Brought correct supplies, drugs, and drug concentrations into the hood
Did not bring unnecessary supplies into clean room or hood area
All supplies & drugs were cleaned prior to bringing them into the clean room area
Supplies were placed in the hood using proper aseptic technique
Ampule neck was cleared of fluid and cleaned with sterile alcohol before breaking
Ampule neck was wrapped with gauze and broke properly
Filter device was used to withdraw contents of ampule
Did not spill contents of ampule when drawing up liquid
Filter device was removed and proper needle/syringe device was used to measure correct amount of drug
If needle was recapped the proper device or scooping method was used to prevent sticks
Syringe was checked to assure correct amount of drug was drawn up (no bubbles, etc.)
Additive port on container was cleaned with sterile alcohol before adding drug
Did not core or puncture side of additive port when adding drug to container
Properly mixed contents of container and inspected for incompatibilities or particulates
Additive port was cleaned with sterile alcohol & tamperproof seal placed over port
Glass and sharps were placed in the appropriate disposal container
Did not utilize outer 6 inches of hood or work too close to sides/back of hood
Did not contaminate needle, syringe, vial, ampule, or other sterile components
Disinfected sterile gloves routinely by wiping with sterile 70% Isopropyl alcohol during compounding process
Did not take hands out of hood or leave the clean room during the mixing process
Did not contaminate the hood by coughing, sneezing, chewing gum, or excessive talking

Rows	Yes	N/A
Did not wear jewelry, false nails, makeup, etc. inside the hood
Donned appropriate apparel as required by USP 797
Washed hands & cleaned hood correctly before beginning compounding process
Correctly performed all required calculations prior to entering the clean room
Brought correct supplies, drugs, and drug concentrations into the hood
All supplies & drugs were cleaned prior to bringing them into the clean room area
Supplies were placed in the hood using proper aseptic technique
Removed dust cover and cleaned rubber diaphragm with sterile alcohol swab
Attached needle to syringe without contaminating sterile components or blocking first air
Inserted needle correctly into diaphragm to prevent coring & used proper milking technique to withdraw contents
Did not remove needle from vial until all air bubbles were removed and volume verified
Removed air bubbles correctly and did not spill any liquid or aspirate contents
Needle was withdrawn correctly from vial to prevent spilling or aspirating
Withdrew correct amount of diluent if reconstituting a powder vial
Recleaned diaphragm with sterile alcohol swab prior to reinserting needle, if powder vial
Mixed powder with liquid correctly without shaking vial contents, if reconstituting
Checked (reconstituted) liquid for incompatibilities or particulate matter & correct volume before injecting
If needle was recapped the proper device or scooping method was used
Additive port was cleaned with sterile alcohol and was not cored or punctured when adding drug to container
Properly mixed the contents of container & inspected for incompatibilities/particulates
Additive port was cleaned with sterile alcohol & tamperproof seal placed over port
Properly affixed IV label to IV bag without blocking fluid measurements on bag
Disinfected sterile gloves by routinely wiping with sterile 70% Isopropyl alcohol during mixing process
Did not contaminate needle, syringe, vial, or other sterile components
Did not contaminate the hood by coughing, sneezing, chewing gum, or excessive talking
Did not utilize outer 6 inches of hood or work too close to sides/back of hood

Rows	Yes	N/A
Did not wear jewelry, false nails, makeup, etc. inside the hood
Donned appropriate apparel as required by USP 797
Washed hands & cleaned hood properly before beginning compounding process
Correctly performed all required calculations prior to entering clean room
Brought correct supplies, drugs, and drug concentrations into the hood
Did not bring unnecessary supplies into clean room or hood area
All supplies & drugs were cleaned prior to bringing them into the clean room area
Correct base solution and other TPN supplies brought into clean room
Supplies were placed in the hood using proper aseptic technique, added port saver if facility policy
Removed all dust covers and cleaned rubber diaphragms with sterile alcohol swabs
Attached needles to syringes without contaminating sterile components or blocking first air
Inserted needles correctly into diaphragms to prevent coring & used proper milking technique to withdraw contents
Did not remove needles from vial until all air bubbles were removed and volume verified
Removed air bubbles correctly, did not spill any liquid or aspirate contents when removing needles
Withdrew correct amount of each electrolyte or additive
Added electrolytes containing phosphate first to prevent precipitate formation
Added electrolytes containing calcium after additive port was sufficiently cleared of phosphate
Checked all liquid for incompatibilities/ particulate matter & correct volume before injecting
Added colored minerals/vitamins and other additives last
If needle was recapped the proper device or scooping method was used to prevent needle sticks
Additive port was cleaned with sterile alcohol, was not cored/punctured when adding drug to container
Properly mixed the contents of container and inspected for incompatibilities or particulates
Additive port was cleaned with sterile alcohol & tamperproof seal placed over port
Properly affixed IV label to IV bag without blocking fluid measurements on bag
Disinfected sterile gloves by routinely wiping with sterile 70% Isopropyl alcohol during mixing process
Did not contaminate needle, syringe, vial, or other sterile components
Did not contaminate the hood by coughing, sneezing, chewing gum, or excessive talking
Did not utilize outer 6 inches of hood or work too close to sides/back of hood during manipulations

National Sterile Compounding Training

Supervised Practice Documentation

Aseptic Handwashing

Gowning & Gloving

Ampule Preparation

Vial Preparation

TPN Preparation

Horizontal Airflow Hood Cleaning

Vertical Airflow Hood Cleaning

Sterile Solution Label Preparation

Biological Safety Cabinet Cleaning (Optional)

Hazardous Drug Ampule Preparation (Optional)

Hazardous Drug Vial Preparation (Optional)

Sterile Ophthalmic Solution Label Preparation (Optional)

Rows	Yes	N/A
Hood was turned on and let run for at least 30 minutes prior to use
Did not wear makeup, jewelry, false nails, or lab coat, etc. inside the hood
Donned appropriate apparel as required by USP 797
All items were removed from the hood areas to be cleaned
All hood surfaces were first cleaned disinfected with sterile agents/supplies
All hood Surfaces were cleaned second with Sterile water and then with Sterile 70% Alcohol & non-shedding Sterile wipes
The IV pole was first surface cleaned if applicable
The sides of hood were cleaned second, beginning at the top and working in a horizontal outward motion from back to front of the hood with overlapping strokes
The bottom surface of the hood was cleaned last, beginning with the back and working horizontally from side to side with overlapping strokes
Did not clean back wall HEPA filter (must be done by certified technician)
Did not use spray bottles inside hood
Did not contaminate previously cleaned surfaces at any time during cleaning
Did not block first air from HEPA filter with hands, or other objects inside hood
Did not utilize outer 6 inches of hood opening or work too close to sides or back of hood during manipulations
Did not contaminate hood by coughing, sneezing, chewing gum, or excessive talking
Did not leave hood during cleaning process
Did not dispose of trash until end of hood cleaning process
Changed or cleaned prefilter as required by institution

Rows	Yes	N/A
Hood was turned on and let run for at least 30 minutes prior to use
Did not wear jewelry, false nails, or lab coat, etc. inside the hood
Donned appropriate apparel as required by USP 797
All items were removed from the hood areas to be cleaned
All hood surfaces were first cleaned and disinfected with sterile agents/supplies
All hood Surfaces were cleaned second with Sterile water and then with Sterile 70% Alcohol & non-shedding Sterile wipes
The back wall inside of the hood was cleaned first beginning at the top and working side to side in a horizontal motion until you reach the bottom with overlapping strokes
The IV pole was cleaned second if applicable
The side walls inside the hood were cleaned third beginning at the top and working side to side in a horizontal motion until you reach the bottom with overlapping strokes
The bottom surface of the hood was cleaned fourth, beginning with the back working horizontally from side to side with overlapping strokes
The inside of the glass shield was cleaned fifth beginning at the top and working side to side in a horizontal motion until you reach the bottom with overlapping strokes
Lower glass shield, so the opening was not > or < 8 inches, after cleaning inside front shield
The outside of the glass shield was cleaned last beginning at the top and working side to side in a horizontal motion until you reach the bottom with overlapping strokes (new materials used)
Did not use spray bottles inside hood
Did not contaminate previously cleaned surfaces at any time during cleaning
Did not clean top of hood HEPA filter (must be done by certified technician)
Did not leave hood during cleaning process
Did not block first air from HEPA filter with hands, or other objects inside hood
Did not utilize outer 6 inches of hood opening or work too close to sides/back/top of hood
Did not block air-intake grills at anytime
Changed or cleaned prefilter as required by institution

Rows	Yes	N/A
Label followed the appropriate format as approved by state board of pharmacy
Label contained name, amount, & strength of all solutions
Label contained name, amount, & strength of all additives
Label contained name and identification number (or room number) of patient
Label contained rate of administration/directions for use
Label contained device specific instructions if applicable
Label contained proper storage information as required and auxiliary labels
Label contained date and time for drug administration
Label contained appropriate beyond use (exp.) date/time information
Label contained appropriate identification of person preparing and pharmacist who checked preparation
Label was properly affixed to IV container
Label did not contain any error, typos, or corrections
Performed appropriate calculations as required to prepare label information
Information on label was transcribed correctly from physicians order

Rows	Yes	N/A
Did not wear jewelry, false nails, or long sleeves, etc. inside the biological safety cabinet (BSC)
Donned appropriate apparel as required by USP 800 (i. e. gown, gloves, etc.)
Washed hands, cleaned BSC, and put on appropriate gloves before beginning process
Correctly performed all required calculations before entering negative pressure clean room
Brought the correct supplies, drugs and concentrations into the BSC for preparations
Primed administration set with appropriate solution if applicable
Placed plastic-backed paper drape on BSC counter surface prior to beginning preparations and performed all work on this drape
Made sure glass shield was only open 8 inches and no more
Ampule neck was cleared of fluid before breaking
Ampule neck was cleaned correctly before breaking
Ampule neck was wrapped correctly prior to breaking
Ampule was broken correctly, without spilling
Correct size of luer-lock syringe was utilized
Filter device attached to syringe correctly
Ampule drawn up correctly, without spilling
Cleared all liquid from needle and hub prior to removing filter needle device
Removed filter needle and replaced with closed system vented needle
Air bubbles removed and excess drug injected into sterile closed vial/container
Cleared all liquid from needle and hub prior to removing needle from closed vial/container and did not spill or aspirate contents
Drew up the correct amount of drug & checked measurement before injecting into IV bag
Cleaned additive port on container prior to injecting drug
Did not core or puncture side of additive port when adding drug to container
Properly mixed contents of container and inspected for incompatibilities or particulate matter
Cleaned additive port with sterile alcohol swab to remove any drug residue
Placed appropriate hazardous drug tamperproof seal on additive port
IV bag was placed in hazardous plastic zip-lock bag before removing from hood
Second hazardous plastic zip-lock bag placed over first bag after removed from hood
Appropriate hazardous drug labels placed on container & bag as required by USP 800
Glass and sharp items placed in appropriate hazardous drug disposal containers
Other hazardous waste placed in bags and appropriately labeled containers
Did not bring unnecessary items into hood
Did not utilize outer 6 inches of hood opening or work too close to air-intake grills
Did not contaminate needle, plunger, syringe during preparation
Did not block airflow from HEPA filter with hands, or other objects inside hood
Did not take hands out or leave the hood during preparations