Histology Tech Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

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.

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.

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

HISTOLOGY	Rating Stars (Click)	1	2	3	4
Storage Time of Wet Tissues*
Disposal of Wet Tissues
Universal Histology Precautions
Coverslipping
Preparation of Stains/Reagents
Proper Labeling of Reagents
MOHS Sectioning
GYN Prep & Staining
Non-GYN Prep/Staining
FNA Collections
Thinprep
Electronic Documents
SPECIAL STAIN TECHNIQUES	Rating Stars (Click)	1	2	3	4
Group I
Group II
Group III
Group IV
Group V