Cytotechnologist
Name
Email
LAST 4 OF SSN
This checklist was electronically signed on (Today’s date)
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
Proficiency Scale:
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Screen: #/day
Review: #/day
Ascitic Fluid
Bronchial
Esophageal
Gastric
Spinal
Urine
Other (List)
Other (Rate)
Gyn
Non-Gyn
Saccomanno
Cytolyt
Carbowax
95% Alcohol
Filter Prep
Assist
Make Smears
Collection
Preliminary Diagnosis
Onsite Procedures
Staining
GMS
PAP
IRON
Flow Cytometry
DNA Ploidy
FISH
Classification System Used
Instrumentation
ALab Computer Systems (LIS) Used
Electronic Documentation
List Types
Other
I hereby certify that ALL information I have provided on this skills checklist and all other documentation is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
