Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
  • AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young AdultsMiddle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Standard Precautions
    Isolation Precautions
    Do you have charge/supervisor experience?
    Knowledge of "Do Not Use Abbreviations"
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    IV Pumps
    Other IV Pumps:
    EXPERIENCE
    Hospital Laboratory
    Clinic Experience
    Blood Bank
    PATIENT IDENTIFICATION
    Inpatient Identification
    Infants and Young Children Identification
    Emergency Department Identification
    Ambulatory patient Identification
    EQUIPMENT
    Alcohol Swabs
    Arterial Blood Gas Kits
    Cotton Swabs
    Occult Blood Packets
    Heel Warmers
    Infant Restraints
    Laboratory Requisitions
    Serum Separators
    Vacutainer holder
    Vacutainer Tubes
    Order of Tubes
    Blood Culture Bottles
    Blood Culture Preparation Kits
    Centrifuge
    24 Hour Urine Containers
    Capillary Blood Kits
    Bacteria Media
    Drug Screen Kits
    Ova parasite Containers
    Legal Blood Draw Kits
    Paternity Blood Draw Kits
    RSV Kits
    Glucola
    COMPLICATIONS/TROUBLESHOOTING
    Fainting
    Hematoma
    Failure to Draw Blood
    Petechiae
    Excessive Bleeding
    Mastectomy
    Edema
    Collapsed Veins
    Hemolysis
    Burned or Scarred Areas