MLT Practicum
Immunology/Serology
Performance Checklist
Site:
Name: ________________________________________________
Competency and Performance Evaluation
Evaluation Code
Functional Area/Competency Criteria
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
Page 1 of 5
Student
Performed
Concept
Discussed
PROFICIENCY
Student must be proficient (able to perform independently) in the following
procedures:
Observation
(Check all that apply)
Site
Instructor
Initials / Date
Immunology/Serology
Performance Checklist
Site:
Name: ________________________________________________
Competency and Performance Evaluation
Evaluation Code
Functional Area/Competency Criteria
Critical Control Points (CCP)
Record Daily Temperatures
Student
Performed
Student must be proficient in (able to perform independently)
the following procedures:
Concept
Discussed
Observation
(Check all that apply)
Site
Instructor
Initials / Date
1 = Below average
2 = Average
3 = Above average
4 = Exceeds
1
2
3
4
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
Mono Screen
1
2
3
4
Rheumatoid Factor
1
2
3
4
Antistreptolysin O
1
2
3
4
Rubella Screen
1
2
3
4
1
2
3
4
1
2
3
4
Indirect Immunofluorescent Assay:
Latex Agglutination:
Nonlatex Agglutination:
RPR
Hemagglutination:
Cold Agglutinin
Page 2 of 5
MLT Practicum
Immunology/Serology
Performance Checklist
Name: ________________________________________________
Site:
Competency and Performance Evaluation
Evaluation Code
Rating Score
Functional Area/Competency Criteria
Critical Control Points (CCP)
Student
Performed
Student must be proficient in (able to perform independently)
the following procedures:
Concept
Discussed
Observatio
n
(Check all that apply)
(Circle one)
Site
Instructor
Initials / Date
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
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
Hepatitis B Surface Antigen
1
2
3
4
Hepatitis B Core Antibody, Total
1
2
3
4
Electrophoresis:
Chemiluminescent Analyzer:
Page 3 of 5
Immunology/Serology
Performance Checklist
Site:
Name: ________________________________________________
Hepatitis B Surface Antibody
1
2
3
4
Hepatitis B Core IgM
1
2
3
4
Competency and Performance Evaluation
Evaluation Code
Rating Score
Functional Area/Competency Criteria
Critical Control Points (CCP)
Student
Performed
Student must be proficient in (able to perform independently)
the following procedures:
Concept
Discussed
Observation
(Check all that apply)
(Circle one)
Site
Instructor
Initials / Date
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
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
Automated Fluorescent EIA:
Page 4 of 5
MLT Practicum
Immunology/Serology
Performance Checklist
Name: ________________________________________________
Site:
Performance Evaluation
Functional Area/Competency Criteria
Critical Control Points (CCP)
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.
2. Accuracy – Obtains reliable results; recognizes results as normal / abnormal / questionable;
recognizes instrument, clerical and technical errors and takes corrective action.
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.
4. Productivity – Completes assignments within an acceptable amount of time; performs tasks
under pressure without loss of accuracy.
5. Ability to learn – Performs tasks after minimal instruction; transfers information from lecture
to bench work.
6. Thoroughness – Performs tasks to completion; transcribes or enters results accurately and
legibly; demonstrates ability to maintain equipment; follows safety procedures.
7. Cooperation and ability to accept criticism – Cooperates with others; accepts and conforms
to rules; accepts constructive criticism and tries to correct deficiencies.
8. Communication – Gives verbal and written information clearly, accurately and courteously.
9. Organization – Plans and completes work in a manner that efficiently utilizes available
resources and time.
10. Observes hospital policies, dress code, and HIPAA standards.
11. Safety – Observes laboratory safety procedures to include proper use of personal protective
equipment.
TOTAL CHECKLIST SCORE
1 – Below Average
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
1 – Below Average
4 – Exceeds
2 – Average
3 – Above Average
4 – Exceeds
________________
Page 5 of 5
Site
Instructor
Initials / Date
Immunology/Serology
Performance Checklist
Site:
Name: ________________________________________________
Page 6 of 5