SECTION V

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SECTION V Appendix Sponsoring Institution Program Fact Sheet Program Level: Institution: Address: City, State, Zip Code: Telephone:( ) Fax:( ) Email: Agencies that accredit the institution (e.g., JCAHO for hospitals; regional academic associations for colleges; CAP, AABB, FDC, etc. for laboratories): Administrative officer of the organizational unit in which the program is located: Name: Title: Program Director Name: Credentials: Number of students per class: Number of classes per year:_________ List academic and/or clinical affiliate(s). Please use a separate sheet if necessary.

INSTITUTION CITY/STATE ACCREDITED BY NOTE: If the sponsoring institution is a hospital, a Clinical Facility Fact Sheet must also be completed. Didactic Faculty Fact Sheet Name: Position: Employed by: Title: Proportion of time in: Teaching % Administration % Clinical Services % EDUCATION INSTITUTION FIELD OF STUDY DEGREE YEAR Undergraduate Graduate Other (Specify) Certified by: Certification #: Year Certified: Experience (List current position first): INSTITUTION/CITY/STATE POSITION YEARS List principal functions in the education program: List continuing education activities during the past three years: TITLE SPONSOR DATE CEUs Clinical Facility Fact Sheet Institution: Address: City, State, Zip Code: Telephone:( ) Fax:( ) # of Beds: # of Bassinets: # of Annual Admissions: # of Out Patients: Accredited by: Clinical Coordinator or Contact ... more. less.

Person at site: Clinical Laboratory Volume (specify annual number of procedures): Phlebotomies per year: Total space of the laboratory: Total number of sites used by students: TYPE OF SITE NUMBER USED Home Collection Hospital Nursing Homes Outpatient / Drawing Stations Outpatient Clinic Other Number of students in clinical experience assignments: Laboratory staff (convert part-time to full-time equivalent): NUMBER BUDGETED NUMBER EMPLOYED Pathologists Phlebotomists Technologist (baccalaureate) Technician (AD or certificate) Clinical Facility Fact Sheet Page 2 Institution: City, State, Zip Code: Clinical Faculty CERTIFICATION NAME OF INSTRUCTOR YES / NO TYPE NUMBER YEARS OF PHLEBOTOMY EXPERIENCE Example: Jane Doe YES MT ASCP 123456 5 years Clinical Assistant Program Self-Study -Documentation for Standards 9A & 9C NAACLS Competencies Cross-referenced to Course Objectives Note: Provide a brief explanation of how course objectives which have been provided elsewhere in the self-study have been identified in this cross-referencing matrix. Standards 9A and 9C - Relating NAACLS Clinical Assistant Competencies and Course Objectives Course Identification (Title/Course #) Location of Syllabus in Self-Study NAACLS Competencies CORE MODULE 1.0 Define the role of the clinical assistant in the healthcare delivery system as it relates to the point-of-care or clinical laboratory environment. 2.0 Use common medical terminology. 3.0 Demonstrate knowledge of infection control and safety practices. 3.1 Demonstrate accepted practices for infection control, isolation techniques, aseptic techniques and methods for disease prevention. 3.2 Comply with federal, state and locally mandated regulations regarding safety practices. 3.21 Use the OSHA Universal Precaution Standards. 3.22 Use prescribed procedures to handle electrical, radiation, biological and fire hazards. 3.23 Use appropriate practices, as outlined in the OSHA Hazard Communication Standard, including the correct use of the Material Safety Data Sheet as directed. 4.0 Follow standard operating procedures to collect specimens 4.1 Demonstrate basic knowledge of the circulatory, urinary, and other body systems necessary to perform assigned specimen collection tasks. 4.2 Describe the difference between whole blood, serum and plasma. 4.3 Identify and use blood collection equipment. 4.31 Identify the additive by the evacuated tube color. 4.32 Identify and properly use equipment needed to collect blood by venipuncture and capillary (skin) puncture. 4.4 Collect blood specimens by venipuncture. 4.5 Collect blood specimens by capillary (skin) puncture. 4.6 Identify special precautions necessary during blood collections by venipuncture and capillary (skin) puncture. 4.7 List and apply the criteria that would lead to rejection or recollection of a patient sample. 4.8 Instruct patients in the proper collection and preservation for various samples, including blood, spetum and stool. 5.0 Prepare blood and body fluid specimens for analysis according to standard operating procedures. 5.1 Follow standard operating procedures for labeling, transport and processing of specimens, including transport to reference laboratories. 5.2 Describe and follow the criteria for specimens and test results that will be used as legal evidence. 6.0 Prepare/reconstitute reagents, standards and controls according to standard operating procedure. 6.1 Follow laboratory protocol for storage and suitability of reagents standards and controls. 6.2 Recognize and report contamination and/or deterioration in reagents, standards and controls. 7.0 Perform appropriate tests at the clinical assistant level, according to standard operating procedures. 7.1 Compare test results to reference intervals. 7.2 Record results by manual method or computer according to laboratory protocol. 7.3 Report STAT results of completed tests according to laboratory protocol. 7.4 Recognize critical values and follow established protocol regarding reporting. 7.5 Clean glass and plastic labware. 7.6 Use pipetting equipment. 7.7 Use measurement equipment such as beakers and flasks. 8.0 Perform and record vital sign measurements. 8.1 Perform and record blood pressure measurement. 8.2 Perform and record pulse rate. 8.3 Perform and record body temperature. 8.4 Recognize and report abnormal values for vital sign measurement using predetermined criteria. 9.0 Follow established quality control protocols to include maintenance and calibration of equipment. 9.1 Perform quality control procedures. 9.2 Record quality control results. 9.3 Identify and report control results that do not meet pre- determined criteria. 10.0 Communicate (verbally and non-verbally) effectively and appropriately in the workplace. 10.1 Maintain confidentiality of privileged information on individuals. 10.2 Value diversity in the workplace. 10.3 Interact appropriately and professionally with other individuals. 10.4 Discuss the major points of the American Hospital Association's Patient's Bill of Rights or the Patient's Bill of Rights from the institution. 10.5 Model professional appearance and appropriate behavior. 10.6 Follow written and verbal instructions in carrying out testing procedures. 11.0 Use information systems necessary to accomplish job functions. 12.0 Identify and report potential pre-analytical errors that may occur during specimen collection, labeling, transporting and processing. OPTIONAL MODULES BEYOND CORE CHEMISTRY MODULE 1.0 Use common clinical chemistry terminology as it relates to the point-of-care or clinical laboratory environment. 2.0 Prepare, store and dispose of specimens for chemistry analysis according to standard operating procedures. 3.0 Determine suitability of specimens for chemistry procedures according to the test requested, appropriate patient preparation/method of collection, time of collection/processing, storage, hemolysis/lipemia and interfering substances. 4.0 Assemble/prepare reagents, standards and controls for chemistry tests. 5.0 Perform appropriate tests at the clinical assistant level. 6.0 Recognize technical testing errors for each test performed. 7.0 Report results of procedures using pre-determined criteria. 8.0 Follow established quality control procedures specific to chemistry tests, including maintenance and instrument calibration. 9.0 Maintain inventory control and supplies for chemistry tests. DONOR ROOM MODULE 1.0 Use common donor room, collection processing and component preparation terminology as it relates to the point-of- care or clinical laboratory environment. 2.0 According to standard operating procedures, perform donor screening. 2.1 Complete donor medical/social history. 2.2 Complete measurement of donor temperature. 2.3 Complete donor hemoglobin measurement. 2.4 Complete blood pressure measurement. 2.5 Perform donor pulse rate. 3.0 Perform unit collection procedures as defined by established regulations. 3.1 Follow the procedure for donor identification. 3.2 Follow the proper skin preparation procedure and describe its importance. 3.3 Perform donor collection, donor assessment during and after collection and troubleshooting actions for inadequate blood flow and donor reaction. 3.4 Strip unit tubing, mix and package for transport. 4.0 Follow procedures for the component preparation system. 4.1 Prepare components according to established regulations. 4.2 Follow the procedure for packing and shipping of collected blood bags and testing tubes. 4.3 Receive and distribute collected blood components. 4.4 Prepare packed red blood cells, plasma, platelets and cryoprecipitates. 4.5 Follow storage requirements for blood and blood components. 5.0 Follow established quality control procedures specific to donor room collection/component screening, including maintenance and instrument calibration. 5.1 Comply with current Good Manufacturing Practices (GMP). 5.2 Determine suitability of specimens according to pre- determined criteria. 6.0 Follow pre-determined criteria for unit suitability and lot release. 7.0 Maintain inventory control and supplies for donor screening, collection processing and component preparation. HEMATOLOGY MODULE 1.0 Use common hematology terminology as it relates to the point-of-care or clinical laboratory environment. 2.0 Prepare, store and dispose of specimens for hematology analysis according to standard operating procedures. 3.0 Determine suitability of specimens for hematology procedures related to the test requested, appropriate patient preparation/method of collection, time of collection/processing, storage and interfering substances 4.0 Assemble/prepare reagents, standards and controls for hematology tests. 5.0 Prepare and stain slides for further analysis. 6.0 Perform hematology procedures at the clinical assistant level. 7.0 Recognize technical testing errors for each test performed. 8.0 Follow established quality control procedures specific to hematology tests, including maintenance and instrument calibration. 9.0 Maintain inventory control and supplies for hematology tests. IMMUNOLOGY MODULE 1.0 Use common immunology terminology as it relates to the point-of-care or clinical laboratory environment. 2.0 Prepare, store and dispose of specimens for immunology testing according to standard operating procedures. 3.0 Determine suitability of specimens for immunology procedures related to the test requested, appropriate patient preparation/method of collection, time of collection/processing, storage and interfering substances. 4.0 Assemble/prepare reagents, standards and controls for immunology tests. 5.0 Perform immunology tests at the clinical assistant level. 6.0 Recognize technical testing errors for each test performed. 7.0 Report results of tests using pre-determined criteria. 8.0 Follow established quality control procedures specific to immunology tests, including maintenance and instrument calibration. 9.0 Maintain inventory control and supplies for immunology tests. MICROBIOLOGY MODULE 1.0 Use common microbiology terminology as it relates to the point-of-care or clinical laboratory environment. 2.0 Follow special safety procedures and aseptic technique required for processing microbiology specimens. 3.0 Prepare, store, dispose of and properly transport specimens for microbiology testing according to standard operating procedure. 4.0 Determine suitability of specimens for microbiology procedures related to the test requested, appropriate patient preparation/method of collection, time of collection/processing, storage and interfering substances. 5.0 Assemble/prepare reagents, standards and controls for microbiology procedures. 6.0 Prepare and stain slides for further analysis. 7.0 Perform microbiology testing at the clinical assistant level. 8.0 Recognize technical errors for each test performed. 9.0 Report results of procedures using pre-determined criteria. 10.0 Perform pre-determined quality control procedures specific to microbiology testing, including maintenance and instrument calibration. 11.0 Maintain inventory control and supplies for microbiology procedures. URINALYSIS MODULE 1.0 Use common urinalysis terminology as it relates to the point- of-care or clinical laboratory environment. 2.0 Prepare, store, dispose of and properly transport specimens for urinalysis testing according to standard operating procedure. 3.0 Instruct patients in the proper collection and preservation for various urine samples, including mid-stream, random, clean catch, timed collections, collections for drug screening and urine pregnancy tests. 4.0 Determine suitability of specimens for urinalysis procedures related to the test requested, appropriate patient preparation/method of collection, time of collection/processing, storage and interfering substances. 5.0 Assemble/prepare reagents, standards and controls for urinalysis testing. 6.0 Prepare slides for microscopic examination. 7.0 Perform urinalysis tests at the clinical assistant level. 8.0 Recognize technical errors for each test performed. 9.0 Report results of tests using pre-determined criteria. 10.0 Perform pre-determined quality control procedures for urinalysis tests, including maintenance and instrument calibration. 11.0 Maintain inventory control and supplies for urinalysis testing. Phlebotomy Program Self-Study -Documentation for Standards 9A & 9C NAACLS Competencies Cross-referenced to Course Objectives Note: Provide a brief explanation of how course objectives which have been provided elsewhere in the self-study have been identified in this cross-referencing matrix. Standards 9A and 9C - Relating NAACLS Phlebotomy Competencies and Course Objectives Course Identification (Title/Course #) Location of Syllabus in Self-Study NAACLS Competencies 1.1 Identify the health care providers in hospitals and clinics and the phlebotomist's role as a member of this health care team. 1.2 Describe the various hospital departments and their major functions in which the phlebotomist may interact in his/her role. 1.3 Describe the organizational structure of the clinical laboratory department. 1.4 Discuss the roles of the clinical laboratory personnel and their qualifications for these professional positions. 1.5 List the types of laboratory procedures performed in the various sections of the clinical laboratory department. 1.6 Describe how laboratory testing is used to assess body functions and disease. 1.7 Define medical terminology commonly used in the laboratory 2.1 Identify policies and procedures for maintaining laboratory safety. 2.2 Demonstrate accepted practices for infection control, isolation techniques, aseptic techniques and methods for disease prevention. 2.2.1 Identify and discuss the modes of transmission of infection and methods for prevention. 2.2.2 Identify and properly label biohazardous specimens. 2.2.3 Discuss in detail and perform proper infection control techniques, such as handwashng, gowning, gloving, masking, and double-bagging. 2.2.4 Define and discuss the term cnosocomial infection d. 2.3 Comply with federal, state and locally mandated regulations regarding safety practices. 2.3.1 Use the OSHA Standard Precautions 2.3.2 Use prescribed procedures to handle electrical, radiation, biological and fire hazards. 2.3.3 Use appropriate practices, as outlined in the OSHA Hazard Communication Standard, including the correct use of the Material Safety Data Sheet as directed. 2.4 Describe measures used to insure patient safety in various patient settings, i.e., inpatient, outpatient, pediatrics, etc. 3.00 Demonstrate basic understanding of the anatomy and physiology of body systems and anatomic terminology in order to relate major areas of the clinical laboratory to general pathologic conditions associated with the body systems. 3.1 Describe the basic functions of each of the main body systems, and demonstrate basic knowledge of the circulatory, urinary, and other body systems necessary to perform assigned specimen collection tasks. 3.2 Identify the veins of the arms, hands, legs and feet on which phlebotomy is performed. 3.3 Explain the functions of the major constituents of blood, and differentiate between whole blood, serum and plasma. 3.4 Define hemostasis, and explain the basic process of coagulation and fibrinolysis. 3.5 Discuss the properties of arterial blood, venous blood, and capillary blood. 4.00 Demonstrate understanding of the importance of specimen collection and specimen integrity in the delivery of patient care. 4.1 Describe the legal and ethical importance of proper patient/sample identification. 4.2 Describe the types of patient specimens that are analyzed in the clinical laboratory. 4.3 Define the phlebotomist 9s role in collecting and/or transporting these specimens to the laboratory. 4.4 List the general criteria for suitability of a specimen for analysis, and reasons for specimen rejection or recollection. 4.5 Explain the importance of timed, fasting and stat specimens, as related to specimen integrity and patient care. 5.00 Demonstrate knowledge of collection equipment, various types of additives used, special precautions necessary and substances that can interfere in clinical analysis of blood constituents. 5.1 Identify the various types of additives used in blood collection, and explain the reasons for their use. 5.2 Identify the evacuated tube color codes associated with the additives. 5.3 Describe substances that can interfere in clinical analysis of blood constituents and ways in which the phlebotomist can help to avoid these occurrences. 5.4 List and select the types of equipment needed to collect blood by venipuncture, capillary, and arterial puncture. 5.5 Identify special precautions necessary during blood collections by venipuncture, capillary, and arterial puncture. 6.00 Follow standard operating procedures to collect specimens. 6.1 Identify potential sites for venipuncture, capillary, and arterial punctures. 6.2 Differentiate between sterile and antiseptic techniques. 6.3 Describe and demonstrate the steps in the preparation of a puncture site. 6.4 List the effect of tourniquet, hand squeezing and heating pads on capillary puncture and venipuncture. 6.5 Recognize proper needle insertion and withdrawal techniques including direction, angle, depth and aspiration, for arterial puncture and venipuncture. 6.6 Describe and perform correct procedure for capillary collection methods on infants and adults. 6.7 Identify alternate collection sites for arterial, capillary and venipuncture. Describe the limitations and precatutions of each. 6.8 Name and explain frequent causes of phlebotomy complications. Describe signs and symptoms of physical problems that may occur during blood collection. 6.9 List the steps necessary to perform an arterial, venipuncture and/or capillary puncture in chronological order. 6.10 Follow standard operating procedures to perform a competent/effective venipuncture on a patient. 6.11 Follow standard operating procedures to perform a competent/effective capillary puncture on a patient. 7.00 Demonstrate understanding of requisitioning, specimen transport and specimen processing. 7.1 Describe the standard operating procedure for a physician requesting a laboratory analysis for a patient. Discuss laboratory responsibility in responding to physician requests. 7.2 Instruct patients in the proper collection and preservation for various samples, including blood, sputum, and stools. 7.3 Explain methods for transporting and processing specimens for routine and special testing. 7.4 Explain methods for processing and transporting blood specimens for testing at reference laboratories. 7.5 Describe the potential clerical and technical errors that may occur during specimen processing. 7.6 Identify and report potential pre-analytical errors that may occur during specimen collection, labeling, transporting, and processing. 7.7 Describe and follow the criteria for specimens and test results that will be used as legal evidence, i.e. paternity testing, chain of custody, blood alcohol levels, etc. 8.0 Demonstrate understanding of quality assurance and quality control in phlebotomy. 8.1 Describe the system for monitoring quality assurance in the collection of blood specimens. 8.2 Identify policies and procedures used in the clinical laboratory to assure quality in the obtaining of blood specimens. 8.2.1 Perform quality control procedures. 8.2.2 Record quality control results. 8.2.3 Identify and report control results that do not meet pre- determined criteria. 9.0 Communicate (verbally and nonverbally) effectively and appropriately in the workplace 9.1 Maintain confidentiality of privileged information on individuals. 9.2 Value diversity in the workplace. 9.3 Interact appropriately and professionally with other individuals. 9.4 Discuss the major points of the American Hospital Associations 9 Patient 9s Bill of Rights or the Patient 9s Bill of Rights from the institution. 9.5 Model professional appearance and appropriate behavior. 9.6 Model professional appearance and appropriate behavior. 9.7 Define the different terms used in the medicolegal aspect for phlebotomy and discuss policies and protocol designed to avoid medicolegal problems. 9.8 List the causes of stress in the work environment and discuss the coping skills used to deal with stress in the work environment. 9.9 Demonstrate ability to use computer information systems necessary to accomplish job functions. Self-Study Documentation for Standard 9D Relating Evaluation Items to Course Objectives Note: Use this matrix as a cover sheet for each sample evaluation item submitted as part of the self- study. Standard 9D - Relating Evaluation Items to Phlebotomy Course Objectives Type of Evaluation Submitted: Exam Skills checklist Clinical Evaluation Affective Evaluation Other (list): Evaluation Item # Corresponds to Objective # Located in Course (Title/Course #)

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