COMPETENCY ASSESSMENT FORM KKDHL-GEN-0018Version 3.

0
Effective Date: January, 2016 Revision 2.0 Supersedes Version 2

NAME OF STAFF ASSESSED:________________________ DATE ASSESSED_______________

DEPARTMENT:
TESTS/TASKS ASSESSED ON:

SAMPLE HANDLING
INDICATOR EVALUATION SCORE
METHOD
Specimens received in appropriate containers. DO/RR/TR/Q/PT Y N NA
Labels specimens correctly DO/RR/TR/Q//PT Y N NA
Receives, processes, specimens appropriately. DO/RR/TR/Q/PT Y N NA
Evaluates specimens and test orders. DO/RR/TR/Q/PT Y N NA
Fills sample rejection logs and communicates any errors to wards. DO/RR/TR/Q/PT Y N NA
Distributes specimens to appropriate departments for other tests. DO/RR/TR/Q/PT Y N NA
Stores specimens appropriately. DO/RR/TR/Q/PT Y N NA

SAMPLE STORAGE
INDICATOR EVALUATION SCORE
METHOD
Stores specimen appropriately DO/RR/TR/Q/PT Y N NA
Aliquots specimen and store at the right temperature DO/RR/TR/Q/PT Y N NA
Stores specimen at the temperature after testing DO/RR/TR/Q/PT Y N NA
Maintains freezer/refrigerator in an organized manner. DO/RR/TR/Q/PT Y N NA

TEST PERFORMANCE
INDICATOR EVALUATION SCORE
METHOD
Prepares reagents correctly DO/RR/TR/Q/PT Y N NA
Dispenses specimens and reagents appropriately. DO/RR/TR/Q/PT Y N NA
Maintains specimen identity throughout the whole process DO/RR/TR/Q/PT Y N NA
Performs tests according to SOP. DO/RR/TR/Q/PT Y N NA
Obtains accurate results DO/RR/TR/Q/PT Y N NA
Complies with safety protocol. DO/RR/TR/Q/PT Y N NA

QUALITY CONTROL
INDICATOR EVALUATION SCORE
METHOD
Runs quality controls as defined in SOP DO/RR/TR/Q/PT Y N NA
Runs appropriate levels of quality controls DO/RR/TR/Q/PT Y N NA
Plots QC in LJ Charts DO/RR/TR/Q/PT Y N NA
Verifies QC is in acceptable range(Follows west guard rules) DO/RR/TR/Q/PT Y N NA
Files QC results in QC files DO/RR/TR/Q/PT Y N NA
Notifies supervisor or designee of out of range QC results or viola- DO/RR/TR/Q/PT Y N NA
tion of west guard rules
Performs document cause analysis DO/RR/TR/Q/PT Y N NA
Document corrective action DO/RR/TR/Q/PT Y N NA
COMPETENCY ASSESSMENT FORM KKDHL-GEN-0018Version 3.0
Effective Date: January, 2016 Revision 2.0 Supersedes Version 2

INSTRUMENT OPERATION
INDICATOR EVALUATION SCORE
METHOD
Perform daily maintenance DO/RR/TR/Q/PT Y N NA
Adjusts dispensing devices accordingly DO/RR/TR/Q/PT Y N NA
Calibrates instruments DO/RR/TR/Q/PT Y N NA
Performs required function checks DO/RR/TR/Q/PT Y N NA
Performs shutdown maintenance DO/RR/TR/Q/PT Y N NA
Troubleshoots instruments DO/RR/TR/Q/PT Y N NA

INFORMATION MANAGEMENT
INDICATOR EVALUATION SCORE
METHOD
Makes calculations correctly DO/RR/TR/Q/PT Y N NA
Interprets data and evaluates test results correctly DO/RR/TR/Q/PT Y N NA
Documents test results accurately DO/RR/TR/Q/PT Y N NA
Initials on request form and records DO/RR/TR/Q/PT Y N NA
Verifies before releasing results DO/RR/TR/Q/PT Y N NA
Demonstrates procedures for handling abnormal/Panic values DO/RR/TR/Q/PT Y N NA
Handovers communication to other staff DO/RR/TR/Q/PT Y N NA

DATA
INDICATOR EVALUATION SCORE
METHOD
Fills bench records(reagent log, disinfection log) DO/RR/TR/Q/PT Y N NA
Monitors temperature and fills appropriate log DO/RR/TR/Q/PT Y N NA
Documents customer complaints DO/RR/TR/Q/PT Y N NA

PROBLEM SOLVING SKILLS

INDICATOR EVALUATION SCORE
METHOD
Able to identify the presence of a problem DO/RR/TR/Q/PT Y N NA
Able to decide what corrective action is appropriate DO/RR/TR/Q/PT Y N NA
Able to do root cause analysis DO/RR/TR/Q/PT Y N NA
Implements corrective action DO/RR/TR/Q/PT Y N NA
Notifies appropriate personnel DO/RR/TR/Q/PT Y N NA

SAFETY
Uses appropriate PPE DO/RR/TR/Q/PT Y N NA
Explain role in fire safety DO/RR/TR/Q/PT Y N NA
Explains chemical spill clean up DO/RR/TR/Q/PT Y N NA
Wears right type of shoes DO/RR/TR/Q/PT Y N NA
Restrict entry to the lab DO/RR/TR/Q/PT Y N NA
Maintains work area free of clutter. DO/RR/TR/Q/PT Y N NA
Able to separate waste into appropriate bins DO/RR/TR/Q/PT Y N NA
Documents occupational injuries in occurrence logs DO/RR/TR/Q/PT Y N NA
COMPETENCY ASSESSMENT FORM KKDHL-GEN-0018Version 3.0
Effective Date: January, 2016 Revision 2.0 Supersedes Version 2

KEY: On evaluation method, DO=Direct Observation, RR=Record Review, TR=Test Result,

Q= Quiz(Oral/Written) PT=Proficiency testing (attach result sheet)

SCORE LEGEND:

Total points possible: 54 points

Convert points attained into percentage

Method: Points attained X 100

(54-(total # of NA score))

90-100% Excellent
85-89% Very good
75-84% Good (needs supervision)
Less than 75% Needs retraining

TOTAL PERCENTAGE ATTAINED

EMPLOYEE OVERALL PERFOMANCE ACCEPTABLE? YES/NO.

If ‘NO’, describe recommendation/corrective action plan required

Evaluator’s Name and signature: Date:

Laboratory Manager/Designee Approval: Date: