MT/MLT Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyBLOOD BANKPatient Identification Process(Required) 1 2 3 4 ABO/Rh/Antibody Screen & ID(Required) 1 2 3 4 Crossmatch- Immediate Spin/ IgG(Required) 1 2 3 4 Antigen Typing(Required) 1 2 3 4 Antibody Typing: Gel Method(Required) 1 2 3 4 Antibody Typing: Tube Method(Required) 1 2 3 4 Cold Agglutinins(Required) 1 2 3 4 Rhogam Screening(Required) 1 2 3 4 Coombs Test Direct(Required) 1 2 3 4 Coombs Test Indirect(Required) 1 2 3 4 Cord Blood Evaluation(Required) 1 2 3 4 Thawing/ Cooling of Blood Products(Required) 1 2 3 4 Donor Collection Procedures(Required) 1 2 3 4 Issue Blood Product to Pt. Care Area(Required) 1 2 3 4 Emergency Release(Required) 1 2 3 4 Elutions(Required) 1 2 3 4 Transfusion Reaction Workshop(Required) 1 2 3 4 Irradiating Packed Cells(Required) 1 2 3 4 Splitting a Baby Unit(Required) 1 2 3 4 CHEMISTRYSpecimen Preparation(Required) 1 2 3 4 Acetone Analysis(Required) 1 2 3 4 Arterial Blood Gas(Required) 1 2 3 4 B-12 Folates(Required) 1 2 3 4 Cardiac Enzymes(Required) 1 2 3 4 Chromatography- Gas(Required) 1 2 3 4 Chromatography- Thin Layer(Required) 1 2 3 4 Electropheresis(Required) 1 2 3 4 Hormone/ Thyroid(Required) 1 2 3 4 Immunoassay(Required) 1 2 3 4 Osmolality(Required) 1 2 3 4 Therapeutic Drug Monitoring(Required) 1 2 3 4 Tumor Markers(Required) 1 2 3 4 Analyzer Use/ Troubleshooting(Required) 1 2 3 4 Review & Interpretation of QC(Required) 1 2 3 4 HEMATOLOGY / COAGULATIONAutomated Instrument Use(Required) 1 2 3 4 Differential Manual(Required) 1 2 3 4 Sed Rate Manual(Required) 1 2 3 4 Reticulocyte Count(Required) 1 2 3 4 Fetal Hemoglobin(Required) 1 2 3 4 RBC Morphology(Required) 1 2 3 4 Platelet Count(Required) 1 2 3 4 Sickle Cell Prep(Required) 1 2 3 4 Platelet Morphology(Required) 1 2 3 4 Body Fluid Manual Cell Count(Required) 1 2 3 4 Body Fluid Manual diff.(Required) 1 2 3 4 Special Stains- e.g. PAS, LAP, Peroxidase(Required) 1 2 3 4 WBC Stool(Required) 1 2 3 4 Semen Analysis(Required) 1 2 3 4 PT/PTT/INR(Required) 1 2 3 4 D-Dimer(Required) 1 2 3 4 Fibrinogen(Required) 1 2 3 4 Factor Assays(Required) 1 2 3 4 Fibrin Degradation Products(Required) 1 2 3 4 Thrombin Time(Required) 1 2 3 4 IMMUNOLOGY / SEROLOGYRPR/ RPR Titer(Required) 1 2 3 4 Rheumatoid Titer(Required) 1 2 3 4 ANA(Required) 1 2 3 4 HIV Rapid(Required) 1 2 3 4 LE Prep(Required) 1 2 3 4 HIV Antibody Detection(Required) 1 2 3 4 Rubella(Required) 1 2 3 4 CMV(Required) 1 2 3 4 MICROBIOLOGYPlating Micro Specimens(Required) 1 2 3 4 Reading Plates(Required) 1 2 3 4 Gram Stains(Required) 1 2 3 4 Kit Testing- Monospot/ ASO Titer(Required) 1 2 3 4 Kit Testing- Flu/Rapid Strep/ RSV(Required) 1 2 3 4 Wet Prep/ KOH Prep(Required) 1 2 3 4 AFB Stain/ Culture(Required) 1 2 3 4 O&P(Required) 1 2 3 4 CDiff(Required) 1 2 3 4 Occult Blood(Required) 1 2 3 4 Chlamydia(Required) 1 2 3 4 Processing Specimens for Viral/ Fungal Cultures(Required) 1 2 3 4 URINALYSISCrystal Identification(Required) 1 2 3 4 Microscopic Analysis(Required) 1 2 3 4 Macroscopic Analysis(Required) 1 2 3 4 Pregnancy Testing(Required) 1 2 3 4 PHLEBOTOMYNewborn/Neonate (birth to 30 days)(Required) 1 2 3 4 Infant (1 month to 1 year)(Required) 1 2 3 4 Toddler (1 year to 3 years)(Required) 1 2 3 4 Preschooler (3 years to 5 years)(Required) 1 2 3 4 School Age Child (5 years to 12 years)(Required) 1 2 3 4 Adolescents (12 years to 18 years)(Required) 1 2 3 4 Young Adults (18 years to 39 years)(Required) 1 2 3 4 Middle Adults (39 years to 64 years)(Required) 1 2 3 4 Older Adults (64 years to 79 years)(Required) 1 2 3 4 Patient Identification(Required) 1 2 3 4 Elderly Adults (over 79+ years)(Required) 1 2 3 4 PPE Equipment (Gloves, Mask, Etc.)(Required) 1 2 3 4 Adult Venipuncture(Required) 1 2 3 4 Pediatric Venipuncture(Required) 1 2 3 4 Dermal Stick (Finger/Heel)(Required) 1 2 3 4 Butterfly Draw(Required) 1 2 3 4 Arterial Draw(Required) 1 2 3 4 Tube Types and Usage(Required) 1 2 3 4 Centrifuge Operations(Required) 1 2 3 4 Bleeding Time(Required) 1 2 3 4 Blood Culture Collections(Required) 1 2 3 4 Blood Alcohol Collections(Required) 1 2 3 4 Drug Screening Collections(Required) 1 2 3 4 AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
