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
    Electronic Documentation
    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
    Blood Borne Pathogens & Exposure Procedures
    Hazardous Materials & MSDS
    Personal Protective Equipment (PPE)
    EXPERIENCE
    Hospital Laboratory
    Clinic Experience
    Blood Bank
    PATIENT IDENTIFICATION
    Inpatient Identification
    Infants and Young Children Identification
    Emergency Department Identification
    Ambulatory patient Identification
    EQUIPMENT
    Arterial Blood Gas Kits
    Biohazard Waste Containers
    Occult Blood Packets
    Heel Warmers
    Infant Restraints
    Laboratory Requisitions
    Lancets
    Serum Separators
    Vacutainer holder
    Vacutainer 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
    Glucometer
    Blood Collection Tube Usage: Brown-Topped (Lead)
    Gray-topped (Fluoride, potassium oxalate)
    Green-topped (Heparin, Ammonia)
    Lt. Blue-topped (Coagulation)
    Purple-topped (EDTA)
    Red-topped (Plain)
    Serum Separation (Tiger top, speckled, etc.)
    COMPLICATIONS/TROUBLESHOOTING
    Containmination
    Damaged Veins
    Fainting
    Hematoma
    Failure to Draw Blood
    Infection
    Petechiae
    Excessive Bleeding
    Edema
    Collapsed Veins
    Hemolysis
    INFANT/PEDIATRIC COLLECTION
    Finger Stick
    Heel Stick
    Microcapillar Skin Puncture
    Neonatal Screening
    Venipuncture
    SPECIAL CONSIDERATION
    Bleeding Time
    Burned or Scarred Areas
    Dialysis Patients
    Mastectomy
    Therapeutic Drug Monitoring
    Type and Cross Match
    Vascular Access Device
    COLLECTION PROCEDURE EXPERIENCE
    Decontamination of Puncture Site
    Order of Specimen Collection
    Patient Positioning
    Selection of Venipuncture Site
    Tourniquet Application and Removal
    Warming the Puncture Site
    Butterfly Method
    Syringe Method
    Post-Draw Site Pressure and Bandaging
    Proper Waste/Sharps Disposal
    Specialized Specimen Handling
    Specimen Labeling
    Specimen Integrity and Transport