Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
SEROLOGY/IMMUNOLOGY
RPR 0 1 2
FTA-ABS 0 1 2
ANA 0 1 2
LE Cell Prep 0 1 2
C3, C4, Total Complement 0 1 2
Rheumatoid Factor 0 1 2
Monospot 0 1 2
Pregnancy Testing 0 1 2
ASO Titer 0 1 2
Radial Immuno Diffusion 0 1 2
Hemagglutination Inhibition 0 1 2
Rubella Serology 0 1 2
TORCH Studies 0 1 2
Febrile Agglutinations 0 1 2
Body Fluids 0 1 2
Meningitis Screen 0 1 2
BLOOD BANK
Patient Identification 0 1 2
Procedures 0 1 2
Cross Match 0 1 2
Immediate Spin Cross Match 0 1 2
Type RH 0 1 2
Antibody Titer 0 1 2
Antibody Identification 0 1 2
Coombs Test: Direct 0 1 2
Coombs Test: Indirect 0 1 2
Rhogam 0 1 2
Component Preparation 0 1 2
Freezing blood 0 1 2
Cold Agglutinins 0 1 2
Donor Unit Collections 0 1 2
Blood Irradiation 0 1 2
Phasmapheresis 0 1 2
Plateletpheresis 0 1 2
Emergency Release 0 1 2
Special Blood Typing
(Kell, Kidd, Duffy, RH-HR, etc.) 0 1 2
PHLEBOTOMY
Venipuncture 0 1 2
Fingerstick 0 1 2
Heel stick 0 1 2
Pediatric 0 1 2
Pipetting 0 1 2
MLA 0 1 2
To Deliver 0 1 2
To Contain 0 1 2
Volumetric 0 1 2
Operations of Centrifuge 0 1 2
Knowledge of Tube:
Types & Uses: Anticoagulants 0 1 2
Calculation for Solution Prep:
Molarity, Molality 0 1 2
Use of Balance (Weighing) 0 1 2
Basic Safety Guidelines:
Gloves, Goggles, Masks 0 1 2
Communication Skills 0 1 2
Ability to Write Procedures 0 1 2
HEMATOLOGY
CBC 0 1 2
Differential 0 1 2
Reticulocyte Count 0 1 2
Platelet Count 0 1 2
Sickle Cell Prep 0 1 2
Eosinophill Count 0 1 2
Sedimentation Rate 0 1 2
Bleeding Time 0 1 2
PT and PTT 0 1 2
Fibrinogen 0 1 2
Factor Assays 0 1 2
Thrombin Time 0 1 2
Fibrin Split Products/FDP 0 1 2
Platelet Aggregation 0 1 2
Lee-White Clotting Time 0 1 2
Fetal Hemoglobin 0 1 2
Body Fluid Count 0 1 2
Special Stains (PAS, Peroxidase, 0 1 2
Leukocyte Aldaline Phosphatase) 0 1 2
MICROBIOLOGY/VIROLOGY
Gram Stain 0 1 2
Acid Fast Stain(Kinyoun) 0 1 2
Acid Fast Stain (Fluorescent) 0 1 2
India Ink 0 1 2
West Mount-Motility 0 1 2
Darkfield 0 1 2
KOH Prep 0 1 2
Culture Plating 0 1 2
Organism Identification (Aerobic) 0 1 2
Sensitivities: KG 0 1 2
MIC 0 1 2
Blood Culture 0 1 2
Anaerobic Culture 0 1 2
Occult Blood 0 1 2
Ova and Parasite Concentration 0 1 2
Ova and Parasite Identification:
Trichcone 0 1 2
WetMount 0 1 2
Mycobacteria: Culture 0 1 2
Concentration Techniquest 0 1 2
Identification 0 1 2
Chlamydia Culture 0 1 2
Chlamydia Smear 0 1 2
Cell Culture Technique (Viral) 0 1 2
Virus Isolation 0 1 2
Virus Identification 0 1 2
C Difficili Assay 0 1 2
Malarial Examination 0 1 2
Aerobic Culture 0 1 2
CHEMISTRY
Acteone Analysis 0 1 2
Osmolality 0 1 2
CSF/Body Fluid Chemistries 0 1 2
Electrophoresis 0 1 2
Immunoelectrophoresis 0 1 2
Atomic Absorption 0 1 2
Thin Layer Chromatography 0 1 2
Gas Chromatography 0 1 2
Stool Analysis (Fecal Fats) 0 1 2
Instrumentation Used: Include Blood Gases 0 1 2
Drug Monitoring 0 1 2
Main Chemistry Unit 0 1 2
Electrolytes 0 1 2
RIA
Radiation Safety Techniques 0 1 2
Background Counts 0 1 2
Data Reduction 0 1 2
Curves/Regressions 0 1 2
Thyroid Testing 0 1 2
Hormone Testing 0 1 2
Tumor Markers 0 1 2
B12/Folates 0 1 2
Hepatitis 0 1 2
Instrumentation/Gamma Counters 0 1 2
Scintillation Counter 0 1 2
URINALYSIS
Macroscopic UA 0 1 2
Microscopic UA 0 1 2
Crystal Identification 0 1 2
Semen Analysis 0 1 2
Automated Instrumentation 0 1 2
SPEICMEN COLLECTION
Venipuncture 0 1 2
Skin puncture 0 1 2
Point of care testing 0 1 2
Arterial puncture 0 1 2
Neonatal screening 0 1 2
SPECIMEN PROCESSING AND HANDLING
Specimen types/suitability 0 1 2
Operation of centrifuge 0 1 2
Knowledge of tube types & uses 0 1 2
Labeling 0 1 2
Transport 0 1 2
Storage 0 1 2
LABORATORY OPERATIONS
Basic Safety guidelines 0 1 2
Quality control 0 1 2
Infection control 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn (0-30 days) B= Infant (30 days-1 yr) C= Toddler (1-3 yrs) D=Preschool (4-5 yrs) E= School Age (6-12 yrs)
F=Adolescent (13-18 yrs) G= Young Adult (19-39 yrs) H= Middle Adult (40-64 yrs) I = Older Adult (65+ yrs)
A
B
C
D
E
F
G
H
I
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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