NAME: ________________________________DATE SUBMITTED: _____________________

HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________

(Signature over Printed name of RMT in-charge)

H & E Staining Technique

RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
NAME: ________________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: _______________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

H & E Staining Technique

RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
 LABORATORY PERFORMANCE EVALUATION

Average Rating for all Categories for this Evaluation sheet will be interpreted as follows:

Average Rating Interpretation

4 Exemplary
3 Competent
2 Needs Improvement
1 Poor

Please encircle the appropriate rating for each category:

CATEGORY CRITERIA RATIN

G
Procedure was carried out with NO ERROR 4
Accuracy Procedure was carried out with minimal error 3
Procedure was carried out with error to a greater degree 2
Failed to perform procedure correctly 1

Procedure was carried completely 4

Completenes Procedure was carried out with minor flaws 3
s Procedure was carried out partially 2
Failed to perform the procedure entirely 1

Procedure was carried out before the specified time period ends 4
Procedure was carried out exactly within the specified time period 3
Efficiency Procedure was NOT carried out within the specified time period 2
Procedure was NOT able to finish the 1

Exhibit Mastery of procedure on the first try 4

Mastery Mastery was achieved only after performing the procedure a few 3
times
Mastery was achieved after performing the procedure several times 2
Did not achieved mastery of procedure within allotted time of 1
rotation

General Average: _________

Evaluated by: ___________________________________

(Printed Name over Signature of RMT Staff)
NAME: _________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

Cytology Staining Technique

RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
 LABORATORY PERFORMANCE EVALUATION

Average Rating for all Categories for this Evaluation sheet will be interpreted as follows:

Average Rating Interpretation

4 Exemplary
3 Competent
2 Needs Improvement
1 Poor

Please encircle the appropriate rating for each category:

CATEGORY CRITERIA RATIN

G
Procedure was carried out with NO ERROR 4
Accuracy Procedure was carried out with minimal error 3
Procedure was carried out with error to a greater degree 2
Failed to perform procedure correctly 1

Procedure was carried completely 4

Completenes Procedure was carried out with minor flaws 3
s Procedure was carried out partially 2
Failed to perform the procedure entirely 1

Procedure was carried out before the specified time period ends 4
Procedure was carried out exactly within the specified time period 3
Efficiency Procedure was NOT carried out within the specified time period 2
Procedure was NOT able to finish the 1

Exhibit Mastery of procedure on the first try 4

Mastery Mastery was achieved only after performing the procedure a few 3
times
Mastery was achieved after performing the procedure several times 2
Did not achieved mastery of procedure within allotted time of 1
rotation

General Average: _________

Evaluated by: ___________________________________

(Printed Name over Signature of RMT Staff)
NAME: _____________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

QUOTA SHEET
Mounting
RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
NAME: _________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

QUOTA SHEET
Mounting
RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
 LABORATORY PERFORMANCE EVALUATION

Average Rating for all Categories for this Evaluation sheet will be interpreted as follows:

Average Rating Interpretation

4 Exemplary
3 Competent
2 Needs Improvement
1 Poor

Please encircle the appropriate rating for each category:

CATEGORY CRITERIA RATIN

G
Procedure was carried out with NO ERROR 4
Accuracy Procedure was carried out with minimal error 3
Procedure was carried out with error to a greater degree 2
Failed to perform procedure correctly 1

Procedure was carried completely 4

Completenes Procedure was carried out with minor flaws 3
s Procedure was carried out partially 2
Failed to perform the procedure entirely 1

Procedure was carried out before the specified time period ends 4
Procedure was carried out exactly within the specified time period 3
Efficiency Procedure was NOT carried out within the specified time period 2
Procedure was NOT able to finish the 1

Exhibit Mastery of procedure on the first try 4

Mastery Mastery was achieved only after performing the procedure a few 3
times
Mastery was achieved after performing the procedure several times 2
Did not achieved mastery of procedure within allotted time of 1
rotation

General Average: _________

Evaluated by: ___________________________________

(Printed Name over Signature of RMT Staff)
NAME: _______________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

QUOTA SHEET
Receiving of Specimen
RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
NAME: _______________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

QUOTA SHEET
Receiving of Specimen
RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
 LABORATORY PERFORMANCE EVALUATION

Average Rating for all Categories for this Evaluation sheet will be interpreted as follows:

Average Rating Interpretation

4 Exemplary
3 Competent
2 Needs Improvement
1 Poor

Please encircle the appropriate rating for each category:

CATEGORY CRITERIA RATIN

G
Procedure was carried out with NO ERROR 4
Accuracy Procedure was carried out with minimal error 3
Procedure was carried out with error to a greater degree 2
Failed to perform procedure correctly 1

Procedure was carried completely 4

Completenes Procedure was carried out with minor flaws 3
s Procedure was carried out partially 2
Failed to perform the procedure entirely 1

Procedure was carried out before the specified time period ends 4
Procedure was carried out exactly within the specified time period 3
Efficiency Procedure was NOT carried out within the specified time period 2
Procedure was NOT able to finish the 1

Exhibit Mastery of procedure on the first try 4

Mastery Mastery was achieved only after performing the procedure a few 3
times
Mastery was achieved after performing the procedure several times 2
Did not achieved mastery of procedure within allotted time of 1
rotation

General Average: _________

Evaluated by: ___________________________________

(Printed Name over Signature of RMT Staff)
NAME: ____________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

QUOTA SHEET
Use of Microtome/Cutting
RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
NAME: _______________________________DATE SUBMITTED: _____________________
HOSPITAL AFFILIATION: ________________VALIDATED BY: ________________________
(Signature over Printed name of RMT in-charge)

QUOTA SHEET
Use of Microtome/Cutting
RATING OF WORK DONE: 1 – NEEDS IMPROVEMENT, 2 – SATISFACTORY, 3 – GOOD,
4 – GOOD

Date Patient Age Gende SPECIMEN Validated Rating

number r by
 LABORATORY PERFORMANCE EVALUATION

Average Rating for all Categories for this Evaluation sheet will be interpreted as follows:

Average Rating Interpretation

4 Exemplary
3 Competent
2 Needs Improvement
1 Poor

Please encircle the appropriate rating for each category:

CATEGORY CRITERIA RATIN

G
Procedure was carried out with NO ERROR 4
Accuracy Procedure was carried out with minimal error 3
Procedure was carried out with error to a greater degree 2
Failed to perform procedure correctly 1

Procedure was carried completely 4

Completenes Procedure was carried out with minor flaws 3
s Procedure was carried out partially 2
Failed to perform the procedure entirely 1

Procedure was carried out before the specified time period ends 4
Procedure was carried out exactly within the specified time period 3
Efficiency Procedure was NOT carried out within the specified time period 2
Procedure was NOT able to finish the 1

Exhibit Mastery of procedure on the first try 4

Mastery Mastery was achieved only after performing the procedure a few 3
times
Mastery was achieved after performing the procedure several times 2
Did not achieved mastery of procedure within allotted time of 1
rotation

General Average: _________

Evaluated by: ___________________________________

(Printed Name over Signature of RMT Staff)