MLT Practicum

Immunology/Serology

Performance Checklist

Name: ______Site:

Functional Area/Competency Criteria / Competency and Performance Evaluation / Site
Instructor
Initials / Date
Evaluation Code
(Check all that apply)
PROFICIENCY
Student must be proficient (able to perform independently) in the following
procedures: / Observation / Concept Discussed / Student Performed
Review Immunology Policy Manual
The following will be covered for each test performed according to Immunology
Department Procedure Manual:
Specimen requirements
Preparation of calibrators and controls (pipettes used, proper procedure, expiration dates)
Evaluate Quality Control Results
Reporting results / abnormal values / critical values
What to do if beyond linearity / dilutions and diluents / how to report
Handling of micro samples / deadspace
OBSERVATION/DISCUSSION ONLY
Microscopy: ANA Kidney, Crithidia, Hep2 Substrates
Functional Area/Competency Criteria
Critical Control Points (CCP) / Competency and Performance Evaluation / Site
Instructor
Initials / Date
Evaluation Code
(Check all that apply)
Student must be proficient in (able to perform independently)
the following procedures: / Observation / Concept Discussed / Student Performed / 1 = Below average
2 = Average
3 = Above average
4 = Exceeds
Record Daily Temperatures / 1 2 3 4
Indirect Immunofluorescent Assay:
ANA, Antinuclear Antibody / 1 2 3 4
DNA Antibody / 1 2 3 4
Mitochondrial Antibody / 1 2 3 4
Smooth Muscle Antibody / 1 2 3 4
Latex Agglutination:
Mono Screen / 1 2 3 4
Rheumatoid Factor / 1 2 3 4
Antistreptolysin O / 1 2 3 4
Rubella Screen / 1 2 3 4
Nonlatex Agglutination:
RPR / 1 2 3 4
Hemagglutination:
Cold Agglutinin / 1 2 3 4
Functional Area/Competency Criteria
Critical Control Points (CCP) / Competency and Performance Evaluation / Site
Instructor
Initials / Date
Evaluation Code
(Check all that apply) / Rating Score
(Circle one)
Student must be proficient in (able to perform independently)
the following procedures: / Observation / Concept Discussed / Student Performed / 1 = Below average
2 = Average
3 = Above average
4 = Exceeds
Nephelometry:
IgG / 1 2 3 4
IgA / 1 2 3 4
IgM / 1 2 3 4
Haptoglobin / 1 2 3 4
C3 / 1 2 3 4
C4 / 1 2 3 4
Electrophoresis:
Serum Protein Electrophoresis / 1 2 3 4
Urine Protein Electrophoresis / 1 2 3 4
CSF Protein Electrophoresis / 1 2 3 4
Serum Immunofixation Electrophoresis / 1 2 3 4
Urine Immunofixation Electrophoresis / 1 2 3 4
Chemiluminescent Analyzer:
Hepatitis B Surface Antigen / 1 2 3 4
Hepatitis B Core Antibody, Total / 1 2 3 4
Hepatitis B Surface Antibody / 1 2 3 4
Hepatitis B Core IgM / 1 2 3 4
Functional Area/Competency Criteria
Critical Control Points (CCP) / Competency and Performance Evaluation / Site
Instructor
Initials / Date
Evaluation Code
(Check all that apply) / Rating Score
(Circle one)
Student must be proficient in (able to perform independently)
the following procedures: / Observation / Concept Discussed / Student Performed / 1 = Below average
2 = Average
3 = Above average
4 = Exceeds
Hepatitis A Total Antibody / 1 2 3 4
Hepatitis A IgM Antibody / 1 2 3 4
Hepatitis C Antibody / 1 2 3 4
HIV-1,2Grp O Antibody / 1 2 3 4
Rapid Screen HIV-1,2 / 1 2 3 4
Manual EIA: / 1 2 3 4
Anticardiolipin Screen (Total Antibody IgG, IgA, IgM) / 1 2 3 4
Epstein Barr Virus Antibodies (VCA IgG, VCA IgM, Nuclear Antigen, Early Antigen) / 1 2 3 4
Hepatitis B e Antigen / 1 2 3 4
Hepatitis B e Antibody / 1 2 3 4
Automated Fluorescent EIA:
CMV IgG and IgM / 1 2 3 4
Rubeola (measles) / 1 2 3 4
Varicella zoster (chicken pox) / 1 2 3 4
Mumps / 1 2 3 4
Functional Area/Competency Criteria
Critical Control Points (CCP) / Performance Evaluation / Site
Instructor
Initials / Date
Rating Score (circle one)
1. Punctuality and attendance – Is never late or absent unless absolutely necessary; arranges
for and completes makeup time in a timely fashion; never abuses break time. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
2. Accuracy – Obtains reliable results; recognizes results as normal / abnormal / questionable;
recognizes instrument, clerical and technical errors and takes corrective action. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
3. Initiative – Is willing and able to assume responsibility; seeks opportunities to learn; utilizes
time to its maximum; can be depended on to follow through. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
4. Productivity – Completes assignments within an acceptable amount of time; performs tasks
under pressure without loss of accuracy. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
5. Ability to learn – Performs tasks after minimal instruction; transfers information from lecture
to bench work. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
6. Thoroughness – Performs tasks to completion; transcribes or enters results accurately and
legibly; demonstrates ability to maintain equipment; follows safety procedures. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
7. Cooperation and ability to accept criticism – Cooperates with others; accepts and conforms
to rules; accepts constructive criticism and tries to correct deficiencies. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
8. Communication – Gives verbal and written information clearly, accurately and courteously. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
9. Organization – Plans and completes work in a manner that efficiently utilizes available
resources and time. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
10. Observes hospital policies, dress code, and HIPAA standards. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
11. Safety – Observes laboratory safety procedures to include proper use of personal protective
equipment. / 1 – Below Average 2 – Average
3 – Above Average 4 – Exceeds
TOTAL CHECKLIST SCORE / ______

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