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Personnel Files Page 1

Orientation Checklist for New Employees

Name: Job title:

Date hired: Section: Orientation completion date: __________

Within the first 30 days of employment, the following areas must be covered:

1. Hospital Orientation completed (date)

2. Personal locker and laboratory coats/ PPE issued

3. Reviewed job description and performance standards _________________

4. Employee has completed HR paperwork and has ID________________

5. Explained probationary period and orientation/evaluation procedure __________

6. Explained employee performance appraisal system and review date__________________

7. Explained training and regular work schedule ___________________________

8. Placed employee's telephone number/address on section phone list

9. Prepared and explained employee’s personnel file (access, what's kept) ___________

10. Discussed employee's immediate goals ___________________________

11. Mentor assigned

12. Discussed briefly (or had employee read) administrative procedures and policies in the general
administrative manual of the department including:
A. Lab dress code:
B. Disciplinary policies:
C. Union contract: _____________
D. Attendance and Work Schedule: _________________
E. Overtime Approval:
F. Leave requests: _____
G. Clock In/Out and Payroll Procedures: _____________
H. Release of information and patient confidentiality/HIPAA: ________________

13. Gave tour of facility:

A. Laboratory tour:
I. Fire exit plan (evacuation routes)
ii. Each department in the laboratory
iii. Restroom/Locker facilities
iv. Pathologists, Lab Manager/Directors, Lab employees introduced

14. Reviewed customer service expectations with employee __________

15. Reviewed Quality Plan of the Department including Occurrence Reporting System___________

16. Provided computer orientation and training:

A. Employee received sign-on policy and password _______________
B. Employee was trained on LIS procedures relevant to the job ________________

17. Provided training on all policies/procedures specific to the section; signed off on procedures _______

New Employee Orientation Form

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Laboratory Safety Orientation Checklist

Before assignment to a testing/patient area, the employees must have performed the following:

1. Read and reviewed safety manuals and policies:

A. Standard Precautions / Exposure Control Plan / Infection Control / Exposure control plan (if
applicable)
B. Chemical Hygiene Plan
C. Fire safety/evacuation procedures
D. Received training on formaldehyde
E. Received fit-testing (if applicable)
F. Training on TB Exposure Control Plan

2. Reviewed safety procedures:

A. Proper hand washing
B. Gloves (on, off, disposal)
C. Lab coat laundering
D. Sharps precautions
 Sharps precautions
 Use of safety needles/devices
 Sharps disposal
 Broken glass/blood spill clean-up
E. Labeling/handling/storage chemicals/carcinogens
F. Disposal of biohazardous materials
G. Chemical spill clean-up
H. Handling of mercury spills
I. Basic electrical safety
J. Formaldehyde spill clean-up

3. Reviewed the location and use of laboratory safety equipment:

A. Fire extinguishers (employee can use adequately)
B. Fire blankets
C. Fire alarm "pull-stations"
D. Chemical spill kits ; sorbent pillows for formaldehyde
E. Eyewash
F. Safety shower
G. PPE (goggles/gloves etc) required for each task
H. Flammable/acid cabinet
I. MSDS sheets
J. Safety hoods

I have read and understand all of the information presented in the laboratory orientation packet.

___________________________________________________
Employee's signature Date

The above employee has satisfactorily completed all areas of orientation.

___________________________________________________
Manager's signature Date

Completed Checklists must be turned in to the Administrative Secretary in Laboratory Administration

within two months of hire date and will be maintained in the employee’s departmental files.

New Employee Orientation Form

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Personnel Files Page 3

Customer Satisfaction Survey

Excellent Good Average (3 Fair Poor
(5 points) (4 points) points) (2 points) (1 point)
Staff was available in

a timely manner.
Staff was friendly and

cheerful throughout.
Staff greeted you and

offered to help you.
Staff answered your

questions.
Staff showed
knowledge of the 
laboratory/services.
Staff offered pertinent

advice.
Staff was courteous

throughout.
Overall, how would
you rate our customer 
service?

Opened Ended Questions

What did you like best about our customer service?

The lab staff was helpful.

Is there a staff person you would like to commend?

Name: Moses Kigundu

Reason:He took extra time to help me sort out the doctor’s
instructions.
How could we improve our customer service?

Thank you for taking the time to complete our customer service survey.

Customer Satisfaction Survey–Commended

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Personnel Files Page 4

I have read and understood the attached SOP for Creatinine

Analysis.

Chere Moshi , MT (ASCP) 21 May 20XX

Standard Operating Procedure Sign-Off

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Personnel Files Page 5

Quality Manual

I have read and understood the contents of the Quality Manual. I

agree to abide by the regulations stated herein.

Employee Signature Date

Paul Resetter 08-02-2009

Supervisor Signature Date

Godfrey Zacharias 08-02-2009

Quality Manual Sign-Off

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Personnel Files Page 6

Patient Safety Goals Training Certificate

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Personnel Files Page 7

Resume / Curriculum Vitae

Personnel Files Page 8

Educational Diploma or Certificate

Personnel Files Page 9

Position Description
POSITION: Medical Technologist GRADE:

DEPARTMENT: Laboratory COST CENTER:

REPORTS TO: EFFECTIVE DATE:

BASIC FUNCTION:
Perform routine and specialized clinical laboratory testing in areas of the clinical laboratory such as Microbiology,
Hematology, Blood Bank, and/or Clinical Chemistry.

PRINCIPLE DUTIES:
 Perform routine and specialized tests in assigned area of the laboratory; interpret tests results and correlate
laboratory findings with disease state; confirm abnormal results and result discrepancies and initiate follow-up to
resolve discrepancies.
 Evaluate specimen adequacy for test performance.
 Analyze technical problems pertaining to specimen adequacy, laboratory data, and instrumentation; determine
cause and rectifies problems in accordance with guidelines and procedures.
 Calibrate instruments; performs and documents preventative and corrective maintenance, function checks, and
repairs on instruments and equipment.
 Perform, evaluate, and document quality control data and assure that patient results are not reported when
tolerance limits are exceeded; documents quality occurrences in compliance with the quality plan of the
department; advises manager of significant quality control/quality assurance issues. Perform testing on proficiency
testing samples.
 Perform instrumentation troubleshooting to correct problems; refer problems appropriately to instrument vendors.
 Review, repeat, and verify laboratory results according to standard operating procedures; report critical (panic)
values or unusual results in accordance with established policy.
 Prepare reagents and solutions in accordance with established guidelines.
 Assist with inventory management of supplies and assure that laboratory areas remain stocked with needed
supplies.
 Respond to customer inquiries about laboratory results.
 Participate in in-service education programs.
 Participate in the preparation for all inspections by accrediting agencies.
 Participate in training of new employees, residents, and students.
 Maintain confidentiality of patients, families and staff.
 Adhere to customer service standards of hospital and department.
 Perform other job-related duties as assigned.

MINIMUM REQUIREMENTS:
 Bachelor of Science degree in Medical Technology or other related degree and certification as a technologist by ASCP
or equivalent certification.
 1 -3 years of experience in a clinical laboratory.
 Able to sit, stand, walk, bend, reach beyond arm’s length, and type (finger dexterity) for extended periods of time.

SIGNED BY: _______________________________________ DATE: _____________________

Department Head
SIGNED BY: _______________________________________ DATE: _____________________
Division Director
CERTIFIED BY: ____________________________________ DATE: _____________________
Director, Human Resources

I have received a copy of this position description, which I have read, understand, and accept.
_______________________________________ __________________
Employee’s Signature Date

Position Description
Personnel Files Page 10

PERFORMANCE EXPECTATIONS
MEDICAL TECHNOLOGIST
1) Performs laboratory testing with a high level of accuracy with few documented errors.

Exceeds - less than _____________ reporting errors per month

Meets – less than ______________ reporting errors per month
Fails - more than ______ reporting errors per month

2) Performs, validates, and documents QC prior to test release according to defined

department policies.

Exceeds / Standard – performs and documents QC results and corrective actions

100% of the time
Fails – performs and documents QC results and corrective actions less than 100% of
the time

3) Performs laboratory testing in accordance with the published efficiency standards of

department (must define by bench and section of the lab – billables/FTE).

Exceeds- exceeds efficiency standards of the department

Meets - meets efficiency standards of the department
Fails - does not meet efficiency standards of the department

4) Follows policies and procedures of the section/department/hospital consistently.

Exceeds/Meets– follows policies and procedures 100% of the time

Fails – does not follow policies and procedures 100% of the time

5) All testing procedures are performed within defined turnaround time standards; if not
possible, testing delays are communicated to the manager.

Exceeds – All work is completed within required TAT; manager is notified of delays
100% of the time
Meets – Work is usually completed within required TAT; occasional unexplained
delays occur
Fails – Numerous unexplained occurrences of failure to complete work within TAT
limits are documented

6) Performs and documents routine maintenance, calibration, and instrument function checks
per department/section standard operating procedures.

Exceeds – 0 instances of failure to perform and document

Meets – 0 instances of failure to perform; occasional instances of failure to document
Fails - 1 or more instances of failure to perform; occasional instances of failure to
document

7) Calls and documents critical value calls within defined time limit in defined format according
to department policy.

Exceeds/Meets – calls and documents critical calls in defined format 100% of the time
within defined time limit
Fails – calls and documents critical calls in defined format less than 100% of the time;
unexplained delays occurred in communication of critical calls

Performance Expectations
Personnel Files Page 11

I have received a copy of the Corporate Compliance/Privacy

Hotline contact information.

Moses Kidingu, Lab Assistant 22 June 20XX

Receipt of Corporate Compliance

Personnel Files Page 12

Certification by Professional Board

Personnel Files Page 13

Training Certificate – Rapid HIV Testing

Personnel Files Page 14

PERFORMANCE REVIEW
Laboratory Services

EMPLOYEE NAME DATE COMPLETED BY

INSTRUCTIONS

Please fill out this form completely before meeting with the employee for his/her performance review.
Provide written comments for each category and rankings for certain categories. Use specific
examples when providing feedback to assist the employee in understanding what he/she has done
well and why certain skills need improvement.

JOB ACCOMPLISHMENTS

List the employee’s job accomplishments during this review period as compared to your expectations.
Provide an overall rating for the period.

[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

STRENGTHS

List the key strengths that the employee exhibited during the review period as compared to your
expectaions.

COMMUNICATION SKILLS

Describe the strengths and weaknesses of the employee’s communication skills. Provide a rating for
the review period.
[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

AREAS FOR DEVELOPMENT

List the areas of improvement or development.

TEAM BUILDING SKILLS

Describe the strengths and weaknesses of the employee’s team building skills. Provide a rating for the
review period.
[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

GOAL ACCOMPLISHMEN

[Describe and rate the employee’s degree of success in meeting predetermined goals.]
[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

Performance Review
Personnel Files Page 15

TIME MANAGEMENT

Does the employee seem to manage his or her time well? Provide a description and a rating.
[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

CUSTOMER MINDSET

Describe and rate the level of customer-oriented thinking that the employee displays if applicable.
[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

JOB KNOWLEDGE

Describe the level of knowledge that the employee has about his/her job in particular and the company
in general. Rate his/her job knowledge.
[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

OVERALL PERFORMANCE

Provide a summary of the employee’s overall performance. Rate his/her overall job performance.
[ ] 1–Unsatisfactory [ ] 2–Satisfactory [ ] 3–Average [ ] 4–Above average [ ] 5–Outstanding

AGREED UPON ACTIONS

ACTION BY WHOM DUE DATE

COMMENTS

Accepted and agreed to by:

Employee Signature Manager Signature

Date Date

Performance Review
Personnel Files Page 16

I have read and understand the procedure on occurrence

management.

Jonas Livingston, MT (ASCP) 21 May 20XX

Occurrence Management Procedure Review

Personnel Files Page 17

I have read and agreed to abide by the Code of

Ethics policy.

Nayashea Sudiki, Phlebotomist 30 October 20XX

Code of Ethics Review

Personnel Files Page 18

12 November 20XX

Gorette Baker

St. Evangeline’s Hospital Laboratory

Dear Gorette,

Thank you for training our new graduate to order the inventory. I
know that it takes extra time to do training on the job; however, it is
important to have all staff cross-trained on procuring supplies &
reagents. Thank you for sharing the lessons and tools that you
learned at the seminar last week with the other staff who were
unable to attend the seminar.

Sincerely,

Tom Lebina

Laboratory Supervisor

Thank You Letter

Personnel Files Page 19

Disciplinary Action

DATE OF OCCURRENCE __21 DEC 20XX__ DATE OF REPORT___21 DEC 20XX____

TIME OF OCCURRENCE __9 AM___ Requires immediate attention by manager _X Yes __No

PERSONNEL REPORTING OCCURRENCE Alice Reider, MT (ASCP) ______________

PATIENT’S NAME_____NA______________ PATIENT ID____NA___________________

(IF APPLICABLE) (IF APPLICABLE)P

PATIENT’S CLINICIAN NA ______________________________________________________

LOCATION OF OCCURRENCE Laboratory _______________________________________

BRIEF DESCRIPTION OF OCCURRENCE Larry Motatu , MT arrived at work with

slurred speech and strong smell of alcohol on breath. When asked, he admitted

that he had been drinking alcoholic beverages before coming to work. _____

IMMEDIATE ACTION TAKEN (If any) Employee was asked to leave work immediately.

_____________________________________________________________________________

CORRECTIVE ACTION PLAN Employee will be given a warning and notified of the

consequences of a repeat offense – a week suspension without pay. He will be

terminated if a third offense occurs. _________________________________________

FOLLOW-UP ACTION Weekly meeting with supervisor to evaluate any ongoing

issues. _______________________________________________________________________

_____________________________________________________________________________

SIGNATURE OF EMPLOYEE __Larry Motatu__________ DATE __22 DEC 20XX______

SIGNATURE OF SUPERVISOR ___Alice Reider_______ DATE ____22 Dec 20XX__

Disciplinary Action
Personnel Files Page 20

Individual Competency Evaluation

Employee: __Baker Yolanda, Phlebotomist__ Year __20XX_______

Emp. ID# or SSN: 23456789_ Evaluator:__Sole Motatsu, MT______________

Health Dept: ___Zone 4_______________________________ , ________________

Approved Test Complexity Level: ( ) waived, ( ) moderately complex ( ) highly complex

Criteria (Pass/Fail)
Reviewer
Test Procedure Date
A B C D E F G H Initials

Phlebotomy F P F P 2 SM
NOV

Overall Rating (Pass / Fail) Fail

Criteria: A = Specimen handling and processing
B = Test procedure
C = Quality Control testing and recording
D = Results recording and interpretation
E = Instrument maintenance and function checks
F = Assessment of problem solving skills
G = Safety guidelines
H = Problem solving skills

Corrective Action (if any):

Date
21 Nov Employee is lazy. He spends all his time on his cell phone. (I haven’t
20XX seen him on his cell phone, but I know that is what he must be doing.)

Review:
Supervisor: Sole Motatsu , MT ___________ Medical Director: JE Demuli, PhD ________
Date: 2 NOV 20XX ____________________

Individual Competency Evaluation

Personnel Files Page 21

Accidental Exposure to Chemicals Report

Personnel Files Page 22

Employee Contact Information

Employee Contact Information

Personnel Files Page 23

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION DATE OF APPLICATION:______________
Name:
Last First Middle
Address:
Street (Apt) City, State Zip
Alternate Address:
Street City, State Zip
Contact Information: ( ) ( )
Home Telephone Mobile Email
How did you learn about our company?

POSITION SOUGHT: _________________________ Available Start Date:______________

Desired Pay Range: ________________ Are you currently employed? _________________
By Hour or Salary

EDUCATION
Name and Location Graduate? – Degree? Major /
Subjects of Study

High School

College or
University

Specialized
Training,
Trade School, etc…

Other Education
Please list your areas of highest proficiency, special skills or other items that may contribute to
your abilities in performing the above mentioned position.

PREVIOUS EXPERIENCE - Please list beginning from most recent

Dates Employed Company Name Location Role/Title

Job notes, tasks performed and reason for leaving:

Dates Employed Company Name Location Role/Title

Job notes, tasks performed and reason for leaving:

Dates Employed Company Name Location Role/Title

Job notes, tasks performed and reason for leaving:

Application for Employment

Personnel Files Page 24

Individual Competency Evaluation

Employee: ___M. KIGUNDU__________________________ Year ___20XX______

Emp. ID# or SSN: __00009___________________ Evaluator:___James Botolo_

Health Dept: __Region 6______________________________ , ________________

Approved Test Complexity Level: ( ) waived, ( ) moderately complex ( ) highly

complex

Criteria (Pass/Fail)
Reviewer
Test Procedure Date
A B C D E F G H Initials

Manual Differential P P P F P P P P 06 JB
July
FBC P P P P P P F P 06 JB
July
Urinalysis P P P P P P P P 06 JB
July
Rapid HIV P P P P P P F P 06 JB
July
Chemistry – Liver P P P P P P F P 06 JB
Function Tests July
Overall Rating (Pass / Fail) F JB
Criteria: A = Specimen handling and processing
B = Test procedure
C = Quality Control testing and recording
D = Results recording and interpretation
E = Instrument maintenance and function checks
F = Assessment of problem solving skills
G = Safety guidelines
H = Problem solving skills

Corrective Action (if any):

Date
06 July Removed from performing FBC, Manual Diff, Rapid HIV, & Chemistry
20XX Testing; Assigned for Biosafety Training & Re-training on Manual Diff;
Will reassess competency on 13 July

Review:
Supervisor: James Botolo, MT (ASCP) ______Medical Director: J. M. Manzelli, PHD ______
Date: 06 July 20XX ____________________

Individual Competency Evaluation

Personnel Files Page 25

Recording and Investigation of Incidents

Personnel Files Page 26

I have been provided a copy of the employee

handbook and explanation of benefits.

Roy Motebang, MT (ASCP) 16 July 20XX

Employee Handbook / Benefits Receipt

Personnel Files Page 27

OCCURRENCE REPORT FORM

DATE OF OCCURRENCE ___10 JULY 20XX DATE OF REPORT___10 JULY 20XX__

TIME OF OCCURRENCE _10 AM Requires immediate attention by manager X Yes __No

PERSONNEL REPORTING OCCURRENCE J Botolo, PhD ________________________

PATIENT’S NAME____C. Susami_____________ PATIENT ID___BD – 3 March 19ZZ

(IF APPLICABLE) (IF APPLICABLE)P

PATIENT’S CLINICIAN P. Rotgui, MD

LOCATION OF OCCURRENCE Laboratory Reception

BRIEF DESCRIPTION OF OCCURRENCE

Patient presents with blood sample in bag. Upon examining the bag, Mr.

Kigundu noted blood dripping from collection tube. Mr. Kigundu rejects

sample. The angry patient reports complaint to the supervisor (me).

IMMEDIATE ACTION TAKEN (If any) I review specimen rejection policy and

reasons for the rejection. I assure the patient that we will be happy to

process her specimen when it in not a hazard to our laboratory staff.

CORRECTIVE ACTION PLAN Discuss the specimen rejection policy with the

collecting unit. Deliver a copy of specimen rejection policy to this unit.

FOLLOW-UP ACTION Monitor specimen rejection and continue to assess

patterns of rejection and follow up with education and policy

distribution. Discuss creating a clinician handbook with specimen

collection policies for the future. Include this in the agenda of the next

staff meeting.

SIGNATURE OF REVIEWER ___J. Botolo, PhD___ DATE ___11 July 20XX___

Occurrence Report Form

Personnel Files Page 28

27 July 20XX

Moses Kigundu, Medical Technologist

St. Joseph’s Hospital

Dear Mr. Kigundu,

Please accept the commendation of the Laboratory Services

Department of the Ministry of Health for your exceptional service.
This letter is to acknowledge the 20 years of consistent service
provided to the laboratory and to the people of this nation. In honor
of your years of service, please accept our appreciation and this
recognition pin.

Sincerely,

James Lebina, PhD

Dr. James Lebina

Director of Laboratory Services

Ministry of Health

Letter of Commendation from Lab Director