Medical Technologist

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Name*

First Last

Phone*

Email*

Age Specific Care

Proficiency Rating

Frequency Rating

Newborn/Neonate (birth - 30 days) *

Newborn/Neonate (birth - 30 days) proficiency*

Newborn/Neonate (birth - 30 days) frequency*

Infant (30 days - 1 year) *

Infant (30 days - 1 year) proficiency*

Infant (30 days - 1 year) frequency*

Toddler (1 - 3 years) *

Toddler (1 - 3 years) proficiency*

Toddler (1 - 3 years) frequency*

Preschooler (3 - 5 years) *

Preschooler (3 - 5 years) proficiency*

Preschooler (3 - 5 years) frequency*

School Age Child (5 - 12 years) *

School Age Child (5 - 12 years) proficiency*

School Age Child (5 - 12 years) frequency*

Adolescents (12 - 18 years) *

Adolescents (12 - 18 years) proficiency*

Adolescents (12 - 18 years) frequency*

Young Adults (18 - 39 years) *

Young Adults (18 - 39 years) proficiency*

Young Adults (18 - 39 years) frequency*

Middle Adults (39 - 64 years) *

Middle Adults (39 - 64 years) proficiency*

Middle Adults (39 - 64 years) frequency*

Older Adults (64+ years) *

Older Adults (64+ years) proficiency*

Older Adults (64+ years) frequency*

Elderly Adults (over 79+ years) *

Elderly Adults (over 79+ years) proficiency*

Elderly Adults (over 79+ years) frequency*

Experience

Proficiency Rating

Frequency Rating

Hospital *

Hospital proficiency*

Hospital frequency*

MD Office *

MD Office proficiency*

MD Office frequency*

Reference Lab *

Reference Lab proficiency*

Reference Lab frequency*

Other *

Other proficiency*

Other frequency*

List Types:

Chemistry

Proficiency Rating

Frequency Rating

ABG’s (Arterial Blood Gas) *

ABG’s (Arterial Blood Gas) proficiency*

ABG’s (Arterial Blood Gas) frequency*

Acetone Analysis *

Acetone Analysis proficiency*

Acetone Analysis frequency*

Atomic Absorption *

Atomic Absorption proficiency*

Atomic Absorption frequency*

B-12 Folates *

B-12 Folates proficiency*

B-12 Folates frequency*

Cardiac Enzymes *

Cardiac Enzymes proficiency*

Cardiac Enzymes frequency*

CSF Protein *

CSF Protein proficiency*

CSF Protein frequency*

Drug Level Monitoring *

Drug Level Monitoring proficiency*

Drug Level Monitoring frequency*

Electrophoresis *

Electrophoresis proficiency*

Electrophoresis frequency*

Fecal Fats *

Fecal Fats proficiency*

Fecal Fats frequency*

Gas Chromatography *

Gas Chromatography proficiency*

Gas Chromatography frequency*

Hormone/Thyroid *

Hormone/Thyroid proficiency*

Hormone/Thyroid frequency*

Immunoassay *

Immunoassay proficiency*

Immunoassay frequency*

Osmolality *

Osmolality proficiency*

Osmolality frequency*

Thin Layer Chromatography *

Thin Layer Chromatography proficiency*

Thin Layer Chromatography frequency*

Tumor Markers *

Tumor Markers proficiency*

Tumor Markers frequency*

Hematology/Coagulation

Proficiency Rating

Frequency Rating

Automated Instrumentation *

Automated Instrumentation proficiency*

Automated Instrumentation frequency*

Bleeding Time *

Bleeding Time proficiency*

Bleeding Time frequency*

Body Fluid Counts - Manual *

Body Fluid Counts - Manual proficiency*

Body Fluid Counts - Manual frequency*

Bone Marrow Preparation *

Bone Marrow Preparation proficiency*

Bone Marrow Preparation frequency*

CBC (Complete Blood Count) *

CBC (Complete Blood Count) proficiency*

CBC (Complete Blood Count) frequency*

CSF (Cerebral Spinal Fluid) *

CSF (Cerebral Spinal Fluid) proficiency*

CSF (Cerebral Spinal Fluid) frequency*

D-Dimer *

D-Dimer proficiency*

D-Dimer frequency*

Differential - Manual *

Differential - Manual proficiency*

Differential - Manual frequency*

Eosinophil Count *

Eosinophil Count proficiency*

Eosinophil Count frequency*

Factor Assays *

Factor Assays proficiency*

Factor Assays frequency*

Fetal Hemoglobin *

Fetal Hemoglobin proficiency*

Fetal Hemoglobin frequency*

Fibrinogen *

Fibrinogen proficiency*

Fibrinogen frequency*

Fibrin Split Products/FDP *

Fibrin Split Products/FDP proficiency*

Fibrin Split Products/FDP frequency*

Knowledge of Panic Values *

Knowledge of Panic Values proficiency*

Knowledge of Panic Values frequency*

Lee-White Clotting Time *

Lee-White Clotting Time proficiency*

Lee-White Clotting Time frequency*

Platelet Counts *

Platelet Counts proficiency*

Platelet Counts frequency*

Platelet Morphology *

Platelet Morphology proficiency*

Platelet Morphology frequency*

PT/PTT *

PT/PTT proficiency*

PT/PTT frequency*

Reticulocyte Counts *

Reticulocyte Counts proficiency*

Reticulocyte Counts frequency*

Scattergram Interpretation *

Scattergram Interpretation proficiency*

Scattergram Interpretation frequency*

Sedimentation Rates - Manual *

Sedimentation Rates - Manual proficiency*

Sedimentation Rates - Manual frequency*

Semen Analysis *

Semen Analysis proficiency*

Semen Analysis frequency*

Sickle Cell Prep *

Sickle Cell Prep proficiency*

Sickle Cell Prep frequency*

Special Stains - e.g. PAS, LAP, Peroxidase *

Special Stains - e.g. PAS, LAP, Peroxidase proficiency*

Special Stains - e.g. PAS, LAP, Peroxidase frequency*

Thrombin Time *

Thrombin Time proficiency*

Thrombin Time frequency*

WBC Stool *

WBC Stool proficiency*

WBC Stool frequency*

Urinalysis

Proficiency Rating

Frequency Rating

Automated Instrumentation *

Automated Instrumentation proficiency*

Automated Instrumentation frequency*

Crystal Identification *

Crystal Identification proficiency*

Crystal Identification frequency*

Macroscopic *

Macroscopic proficiency*

Macroscopic frequency*

Microscopic *

Microscopic proficiency*

Microscopic frequency*

Pregnancy Testing *

Pregnancy Testing proficiency*

Pregnancy Testing frequency*

Blood Bank

Proficiency Rating

Frequency Rating

Antibody Identification *

Antibody Identification proficiency*

Antibody Identification frequency*

Antibody Screen *

Antibody Screen proficiency*

Antibody Screen frequency*

Antigen Typing *

Antigen Typing proficiency*

Antigen Typing frequency*

Blood Irradiation *

Blood Irradiation proficiency*

Blood Irradiation frequency*

Cold Agglutinins *

Cold Agglutinins proficiency*

Cold Agglutinins frequency*

Component Preparation *

Component Preparation proficiency*

Component Preparation frequency*

Cord Blood Evaluation *

Cord Blood Evaluation proficiency*

Cord Blood Evaluation frequency*

Crossmatch - Immediate Spin / IgG *

Crossmatch - Immediate Spin / IgG proficiency*

Crossmatch - Immediate Spin / IgG frequency*

Deglycerizing Blood *

Deglycerizing Blood proficiency*

Deglycerizing Blood frequency*

Direct Coombs Test *

Direct Coombs Test proficiency*

Direct Coombs Test frequency*

Donor Screening *

Donor Screening proficiency*

Donor Screening frequency*

Donor Unit Collections *

Donor Unit Collections proficiency*

Donor Unit Collections frequency*

Emergency Release *

Emergency Release proficiency*

Emergency Release frequency*

Gel Method *

Gel Method proficiency*

Gel Method frequency*

Indirect Coombs Test *

Indirect Coombs Test proficiency*

Indirect Coombs Test frequency*

Irradiating Packed Cells *

Irradiating Packed Cells proficiency*

Irradiating Packed Cells frequency*

Kell, Kidd, Duffy, RH HR, MNS, Lewis, P *

Kell, Kidd, Duffy, RH HR, MNS, Lewis, P proficiency*

Kell, Kidd, Duffy, RH HR, MNS, Lewis, P frequency*

Patient Identification *

Patient Identification proficiency*

Patient Identification frequency*

Plasmapheresis *

Plasmapheresis proficiency*

Plasmapheresis frequency*

Plateletpheresis *

Plateletpheresis proficiency*

Plateletpheresis frequency*

Rhogam Screening *

Rhogam Screening proficiency*

Rhogam Screening frequency*

Special Blood Typing *

Special Blood Typing proficiency*

Special Blood Typing frequency*

Thawing / Cooling of Blood Products *

Thawing / Cooling of Blood Products proficiency*

Thawing / Cooling of Blood Products frequency*

Tube Method *

Tube Method proficiency*

Tube Method frequency*

Type RH *

Type RH proficiency*

Type RH frequency*

Transfusion Reaction Workshop *

Transfusion Reaction Workshop proficiency*

Transfusion Reaction Workshop frequency*

Microbiology

Proficiency Rating

Frequency Rating

Acid Fast Stain (Kinyoun) *

Acid Fast Stain (Kinyoun) proficiency*

Acid Fast Stain (Kinyoun) frequency*

Acid Fast Stain (Fluorescent) *

Acid Fast Stain (Fluorescent) proficiency*

Acid Fast Stain (Fluorescent) frequency*

Aerobic Culture *

Aerobic Culture proficiency*

Aerobic Culture frequency*

Anaerobic Culture *

Anaerobic Culture proficiency*

Anaerobic Culture frequency*

Anaerobic Identification *

Anaerobic Identification proficiency*

Anaerobic Identification frequency*

Antibiotic Sensitivities *

Antibiotic Sensitivities proficiency*

Antibiotic Sensitivities frequency*

Blood Culture *

Blood Culture proficiency*

Blood Culture frequency*

C Difficili Assay *

C Difficili Assay proficiency*

C Difficili Assay frequency*

Cell Culture *

Cell Culture proficiency*

Cell Culture frequency*

Chlamydia Culture *

Chlamydia Culture proficiency*

Chlamydia Culture frequency*

Chlamydia Smear *

Chlamydia Smear proficiency*

Chlamydia Smear frequency*

Concentration Techniques *

Concentration Techniques proficiency*

Concentration Techniques frequency*

Culture Plating *

Culture Plating proficiency*

Culture Plating frequency*

Darkfield *

Darkfield proficiency*

Darkfield frequency*

Gram Stain *

Gram Stain proficiency*

Gram Stain frequency*

India Ink *

India Ink proficiency*

India Ink frequency*

Kit Testing *

Kit Testing proficiency*

Kit Testing frequency*

KOH Prep *

KOH Prep proficiency*

KOH Prep frequency*

Malarial Examination *

Malarial Examination proficiency*

Malarial Examination frequency*

M.I.C. *

M.I.C. proficiency*

M.I.C. frequency*

Molecular Testing *

Molecular Testing proficiency*

Molecular Testing frequency*

Mycobacteria: Culture *

Mycobacteria: Culture proficiency*

Mycobacteria: Culture frequency*

Occult Blood *

Occult Blood proficiency*

Occult Blood frequency*

Organism Identification *

Organism Identification proficiency*

Organism Identification frequency*

Ova and Parasite *

Ova and Parasite proficiency*

Ova and Parasite frequency*

PCR Testing *

PCR Testing proficiency*

PCR Testing frequency*

Reading Plates *

Reading Plates proficiency*

Reading Plates frequency*

Set Ups *

Set Ups proficiency*

Set Ups frequency*

Trichrome Stain *

Trichrome Stain proficiency*

Trichrome Stain frequency*

Virus Identification *

Virus Identification proficiency*

Virus Identification frequency*

Virus Isolation *

Virus Isolation proficiency*

Virus Isolation frequency*

Wet Mount *

Wet Mount proficiency*

Wet Mount frequency*

Phlebotomy

Proficiency Rating

Frequency Rating

ABG (Arterial Blood Gas) Draws *

ABG (Arterial Blood Gas) Draws proficiency*

ABG (Arterial Blood Gas) Draws frequency*

Arterial Punctures *

Arterial Punctures proficiency*

Arterial Punctures frequency*

Butterfly Draw *

Butterfly Draw proficiency*

Butterfly Draw frequency*

Finger Stick *

Finger Stick proficiency*

Finger Stick frequency*

Heel Stick *

Heel Stick proficiency*

Heel Stick frequency*

MLA *

MLA proficiency*

MLA frequency*

Pediatric *

Pediatric proficiency*

Pediatric frequency*

Pipetting *

Pipetting proficiency*

Pipetting frequency*

Venipuncture *

Venipuncture proficiency*

Venipuncture frequency*

Volumetric *

Volumetric proficiency*

Volumetric frequency*

Serology/Immunology

Proficiency Rating

Frequency Rating

ANA *

ANA proficiency*

ANA frequency*

ASO (anti-streptolysin O) Titer *

ASO (anti-streptolysin O) Titer proficiency*

ASO (anti-streptolysin O) Titer frequency*

C3, C4, Total Complement *

C3, C4, Total Complement proficiency*

C3, C4, Total Complement frequency*

Febrile Agglutinations *

Febrile Agglutinations proficiency*

Febrile Agglutinations frequency*

FTA-ABS (fluorescent treponemal antibody absorption test) *

FTA-ABS (fluorescent treponemal antibody absorption test) proficiency*

FTA-ABS (fluorescent treponemal antibody absorption test) frequency*

Hemagglutination Inhibition *

Hemagglutination Inhibition proficiency*

Hemagglutination Inhibition frequency*

HIV Antibody Detection *

HIV Antibody Detection proficiency*

HIV Antibody Detection frequency*

HIV Rapid *

HIV Rapid proficiency*

HIV Rapid frequency*

Influenza Screening *

Influenza Screening proficiency*

Influenza Screening frequency*

LE Cell Prep *

LE Cell Prep proficiency*

LE Cell Prep frequency*

Meningitis Screen *

Meningitis Screen proficiency*

Meningitis Screen frequency*

Monostat *

Monostat proficiency*

Monostat frequency*

Radial Immuno Diffusion *

Radial Immuno Diffusion proficiency*

Radial Immuno Diffusion frequency*

Rapid Strep *

Rapid Strep proficiency*

Rapid Strep frequency*

Rheumatoid Factor *

Rheumatoid Factor proficiency*

Rheumatoid Factor frequency*

RPR (rapid plasma reagin) *

RPR (rapid plasma reagin) proficiency*

RPR (rapid plasma reagin) frequency*

Rubella Serology *

Rubella Serology proficiency*

Rubella Serology frequency*

Equipment

Proficiency Rating

Frequency Rating

Abbott *

Abbott proficiency*

Abbott frequency*

Advantus *

Advantus proficiency*

Advantus frequency*

Bactech *

Bactech proficiency*

Bactech frequency*

Bayer *

Bayer proficiency*

Bayer frequency*

Beckman Coulter *

Beckman Coulter proficiency*

Beckman Coulter frequency*

BioMerieux *

BioMerieux proficiency*

BioMerieux frequency*

Cellavision *

Cellavision proficiency*

Cellavision frequency*

Clinitek *

Clinitek proficiency*

Clinitek frequency*

COBAS *

COBAS proficiency*

COBAS frequency*

Corning *

Corning proficiency*

Corning frequency*

Dupont *

Dupont proficiency*

Dupont frequency*

GEM *

GEM proficiency*

GEM frequency*

Hitachi *

Hitachi proficiency*

Hitachi frequency*

Iris *

Iris proficiency*

Iris frequency*

MicroScan *

MicroScan proficiency*

MicroScan frequency*

MLA *

MLA proficiency*

MLA frequency*

Ortho / Johnson & Johnson *

Ortho / Johnson & Johnson proficiency*

Ortho / Johnson & Johnson frequency*

Osmometer *

Osmometer proficiency*

Osmometer frequency*

ProVue *

ProVue proficiency*

ProVue frequency*

Roche *

Roche proficiency*

Roche frequency*

Ruby *

Ruby proficiency*

Ruby frequency*

Siemens *

Siemens proficiency*

Siemens frequency*

SQA-V *

SQA-V proficiency*

SQA-V frequency*

Solvia *

Solvia proficiency*

Solvia frequency*

Stago *

Stago proficiency*

Stago frequency*

Sysmex *

Sysmex proficiency*

Sysmex frequency*

Vitro *

Vitro proficiency*

Vitro frequency*

Vitek *

Vitek proficiency*

Vitek frequency*

Vista *

Vista proficiency*

Vista frequency*

Computer/Charting

Proficiency Rating

Frequency Rating

Cerner *

Cerner proficiency*

Cerner frequency*

Clinilab *

Clinilab proficiency*

Clinilab frequency*

CPSI *

CPSI proficiency*

CPSI frequency*

Epic *

Epic proficiency*

Epic frequency*

McKesson *

McKesson proficiency*

McKesson frequency*

Meditech *

Meditech proficiency*

Meditech frequency*

Orchard *

Orchard proficiency*

Orchard frequency*

SafeTrace *

SafeTrace proficiency*

SafeTrace frequency*

Softlab *

Softlab proficiency*

Softlab frequency*

Sunquest *

Sunquest proficiency*

Sunquest frequency*

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Date*

Skills/Competences

Proficiency

Frequency

MEDICAL TECHNOLOGIST

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