University of Texas Medical Branch
School of Health Professions – Department of Clinical Laboratory Sciences
Galveston, Texas 77555-1140
Preceptorship Performance Evaluation
To be completed by the student:
Student Name:
Section of Laboratory
URINALYSIS
Institution
Dates of Training
_________________________________________________________
To be completed by the supervisor of the student:
Name of student’s supervisor:
Institution:
__________________________________________________________
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. Cognitive goals are evaluated
through the use of a quiz based on the study guide questions, which are based on these
preceptorship objectives. This quiz is given by UTMB which is standard for all
students. The following objectives can be used as a checklist for what to have the
student perform and/or to discuss or observe. The clinical instructor of the student
should initial those items discussed, observed, researched or performed. “Not
Applicable/NA” cannot be used as the students can discuss, observe or go read
something about each of the following.
General Procedures
I. Automated Urinalysis
1. perform the analysis of patient urine specimens using the automated system.
2. perform or verify calibration or standardization of the instrument.
3. recognize instrument problems and warnings and perform procedures to correct these problems.
4. following instructor demonstration and using the instrument manual and maintenance manual,
perform, with minimal supervision, maintenance and troubleshooting procedures assigned by the
instructor.
5. following instructor demonstration and using the procedure manual, perform without direct
assistance, urine sample preparation prior to testing.
Objective met
II. Physical and Chemical Urine Testing
1. following instructor demonstration and using the procedure manual, perform without direct
assistance, urine sample preparation prior to testing.
2. using the procedure manual, perform without direct assistance assessment of physical characteristics
Revised 06/22/2010
1
3.
4.
of urine.
using the procedure manual, perform without direct assistance, manual chemical testing of urine
using the procedure manual, perform without direct assistance, reducing substance
III. Microscopic Urine Exam
1. using the procedure manual, perform without direct assistance, urine sample preparation prior to
microscopic examination
2. using the procedure manual, perform with minimal supervision, proper adjustment of the microscope
to be used for microscopic exam.
3. using the procedure manual, perform with minimal supervision, routine microscopic urine exam.
IV. Urine Pregnancy Test
1. using the procedure manual, perform without direct assistance, urine sample preparation prior to
pregnancy testing
2. using the procedure manual, and following instructor demonstration, perform with minimal
supervision, pregnancy testing of urine
Revised 06/22/2010
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
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; 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
2
14. Selected appropriate samples and test methods
15. Selected appropriate reagents and instruments.
16. Evaluated laboratory Data
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 [ ]
Average [ ]
Below Average [ ]
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:
Thank you for your appraisal of this student’s experience at your facility.
Clinical Instructor signature:
Date:
Section Supervisor/Clinical Coordinator:
if different than above
Date:
This evaluation may be given to the student or emailed, mailed or faxed to the student’s UTMB Faculty
instructor.
University of Texas Medical Branch
Revised 06/22/2010
3
Clinical Laboratory Sciences Department
Preceptorship Coordinator
301 University Blvd
Galveston, Texas 77555-1140
Fax: 409-772-9470
Revised 06/22/2010
4