University of Texas Medical Branch
School of Health Professions – Department of Clinical Laboratory Sciences
Galveston, Texas 77555-1140
Preceptorship Performance Evaluation
Student Name:
Section of Laboratory
HEMATOLOGY PRECEPTORSHIP
Clinical Affiliate
Dates of Training
Name of student’s clinical instructor
Purpose
The UTMB CLS student is required to meet cognitive (knowledge), psychomotor (skill)
and affective (attitude) objectives of each preceptorship. This document outlines the
cognitive and psychomotor objectives of the program. The following objectives can be
used as a checklist for what the student can perform and/or to discuss or observe. The
clinical instructor of the student will indicate how the items below were met by placing
a check in one of the columns. The student is responsible for any item that cannot be
discussed, observed or performed on site by reading or researching the information on
line. The Last column will be initialed by the clinical person or by the student if
researched or read about the objective.
O=Observed; D=Discussed; P=Performed; R=Read/researched by the student
GENERAL PROCEDURES
1. Use appropriate personal protective equipment when working with patient samples.
2. Locate all fire extinguishers, eye wash stations and safety showers.
3. Locate Materials Safety Data Sheets, chemicals carcinogens list, and hazardous
chemicals list.
Specimen Preparation
1. Collect or recognize and process without assistance specimens for testing.
2. Describe the technique for performance of the bleeding time test using the
laboratory’s SOP.
3. Recognize unacceptable specimens and follow procedures required when such
specimen are received.
4. Separate, aliquot, label and distribute specimens according to laboratory standard
operating procedure (SOP).
5. Organize patient workload and manage time to complete task assignments, including
QC and QA procedures, in specific time allowed.
6. Apply requirements for special specimen preparation, including body fluids.
7. Accurately dilute specimens, repeat analysis and calculate the true result for all
procedures performed as required.
Laboratory Information System (LIS)
1. Use an LIS to enter patient demographic and laboratory results.
Revised 4/2013
Objectives met
O
D P R
Initials
O
D
P
R
Initials
O
D
P
R
Initials
1
Quality Assurance
1. Accurately and legibly log in and maintain required records at all times. Pipet
accurately at all times
2. Reconstitute control sera and standards with accuracy and reliability without direct
supervision
3. Perform quality assurance procedures for each test analysis and consistently maintain
required documentation.
4. Evaluate quality control data, recognize out-of-control data and perform
troubleshooting measures according to laboratory policies for all laboratory
procedures
5. Apply Westgard rules to quality control decisions, recognize out-of-control situations,
and perform actions outlined in the SOP when these situations occur.
6. Determine and implement the course of action when delta checks are not correlated.
7. Recognize test results that need to be checked by repeat testing and those that are
beyond the limits of linearity and perform procedures as defined by SOP when these
occur.
Reference Ranges
Recognize reference ranges, therapeutic ranges, and critical values and perform
procedures at all times that are required by the SOP when these occur
AUTOMATION
Hematology
1. State the principle of operation and method of determination, for the instrument(s)
utilized in the laboratory in which you are rotating, for each of the following:
 Cell counts (white cell, red cell, platelets, and reticulocytes [where
appropriate])
 Cell identification
 Hemoglobin
 Hematocrit
 Red cell indices
 RDW.
2. Compare impedance and photo-optical methods for counting cells.
3. For each of the tests listed below, perform/describe (NOTE: as appropriate for the
rotation laboratory) the procedure, including reagent and control preparation, state the
normal range and panic values:

Cell count

Hgb

Hct

Red cell indices

RDW

ESR

Reticulocyte count
4. Observe/perform maintenance on the primary automated cell counter/analyzer,
microhematocrit centrifuge, automated ESR [where appropriate].
5. Given common instrument malfunction, find the appropriate trouble-shooting
information and discuss the action to be taken.
6. Observe/perform the following tests
G6 Pd Deficiency Screening
Malaria Screen
Sickle Cell Screen
Protein C and Protein S levels
Circulating Inhibitor
Eosinophil Count
Osmotic Fragility Test
Giemsa Stain (for Malaria differentiation)
O
D
P
R
Initials
O
D
P
R
Initials
O
D
P
R
Initials
O
D
P
R
Initials
1.
Revised 4/2013
2
Hemostasis
1. State the principle of operation and method of clot detection for the instrument(s)
utilized in the laboratory in which you are rotating.
2. Compare and contrast optical vs. elctromechanical methods for clot detection.
3. For each of the tests listed below, perform/describe the procedure, state the normal
range and panic values, and describe the portion of the hemostatic mechanism tested:
 Prothrombin time
 Activated partial thromboplastin time
 Fibrinogen
 FDP
 D-dimer
 Factor assays
 Mixing/correction studies
 Bleeding time
 Platelet aggregation studies
4. Observe/perform maintenance on the primary coagulation instrument.
5. Given an error code or instrument malfunction, find the appropriate trouble-shooting
information and discuss the action to be taken.
MORPHOLOGY
1. Recognize, identify and grade [where appropriate], according to laboratory SOP, the
following in peripheral blood smears (criteria for evaluation – differentials and
morphology grade within 20% of predetermined values)
 Normal mature cells
 Immature cells of each cell line
 Red cell inclusions
 Red cell abnormal shapes and sizes (e.g., anisocytosis, poikilocytosis,
dacryocytes, ovalocytes, microcytes, etc.)
 White cell inclusions
 Abnormalities of white cell structure
2. Recognize, identify and grade [where appropriate], according to laboratory standard
operating procedure (SOP), the following in various body fluid smears:
 Normal mature cells
 Immature cells of each cell line
 Abnormal cells (e.g., tumor cells, L.E. cells, disease specific cells, etc.)
 Abnormalities of white and red cell structure
BODY FLUIDS
1. Discuss the technique for preparation of body fluids for performance of cell counts
and differentials.
2. Perform/observe preparation of body fluids for cell counts and differentials.
3. Discuss special stains that may be performed on body fluids to detect cells and
inclusions that are indicative of certain disease states.
4. Perform cell counts with 100% accuracy and differentials within 20% of the
predetermined values on body fluids.
BONE MARROW
1. Explain the procedure used for collection of bone marrow samples, including sites,
types of sample processing, and preparation of smears.
2. Describe the principle and method for the special stains listed below:
 LAP
 Prussian blue
 peroxidase,
 Sudan Black B
 non-specifc and specific esterase
 dual esterase
 PAS
 TRAP
3. Compare the staining properties of each of the stains listed above and the utility of the
stains in identifying specific cell types.
Revised 4/2013
O
D
P
R
Initials
O
D
P
R
Initials
O
D
P
R
Initials
O
D
P
R
Initials
3
Does NOT meet entry
level Requirements
(<70%)
Technical Knowledge and Competence
1. Recalled the scientific principles of laboratory test procedures
2. Discussed technical and procedural concepts
3. Detected the need for and used problem solving procedures
4. Integrated and practiced safety regulations
5. Explained the principles of quality assurance and quality control
6. Discussed scientific information and the application of principles
as they related to tests performed/sent to reference lab by this
area.
7. Recognized abnormal laboratory data and made correlations with
associated pathology
8. Confirmed the validity of test results and selected additional test
procedures
9. Performed and interpreted diagnostic tests with accuracy
10. Used quality control procedures
11. Calibrated instruments or determined QC requirements for
instruments.
12. Evaluated computer generated data
13. Effectively analyzed malfunctions and trouble shoots instruments
and/or procedures
14. Selected appropriate samples and test methods
15. Selected appropriate reagents/ blood products and instruments.
16. Evaluated laboratory Data
Meets entry level
requirements (70%)
Criteria: please circle the box which you feel represents this
student’s ability during and/or after this preceptorship rotation.
Exceeds entry level
Requirements (>80%)
Scale:
3 = exceeds entry level requirements (>80%) – produces work of high quality
2 = Meets entry level requirements (70%) – requires little duplication of instruction and makes few
errors
1 = does not meet entry level requirements (<70%) - improvement needed.
3
3
3
3
3
3
2
2
2
2
2
2
1
1
1
1
1
1
3
2
1
3
2
1
3
3
3
2
2
2
1
1
1
3
3
2
2
1
1
3
3
3
2
2
2
1
1
1
Please indicate your appraisal of the individual’s performance as a clinical laboratory science professional
by checking one box:
EXCELLENT [ ]
Revised 4/2013
Average [ ]
Below Average [ ]
4
Please provide examples of any marks of “Does not meet entry level Requirements” level 1 and/or any
other comments you would like to make about this student: If you would like the comments to be
private, please email jvincent@utmb.edu. Thank you.
OPTIONAL: Each year one student is picked for the McGanity Scholarship of $500 and recognition at
graduation. We are asking you to help us pick this student by completing a survey online. Do you think
this student’s overall performance was exceptional or a student who represents what you think is the
ideal clinical employee? If yes, please click here to go to the survey site to enter your evaluation:
https://survey.utmb.edu/TakeSurvey.aspx?SurveyID=8lL19p8
You may also give this link to any of your staff. Thank you for your time.
Thank you for your appraisal of this student’s experience at your facility.
Clinical Facility Instructor signature:
Section Supervisor/Clinical Coordinator:
if different than above
Date:
Date:
This evaluation must be given to the student. The student is responsible for scanning and submitting on
Blackboard.
Revised 4/2013
5