Phlebotomy Competency Skills Checklist
   LAST 4 OF SSN      
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.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

Rating Stars (Click) Preparation 1 2 3 4  
Introduces self to patient and explains blood tests have been ordered by physician.  
Identifies the patient with two unique identifiers (armband, ask for name & DOB).
Compare patient ID information with barcode label.
Checks testing requirements (ie fasting).  
Prepares supplies and tube selection.  
Washes hand, dons gloves.  
Rating Stars (Click) Getting Started 1 2 3 4  
Positions Patient and applies tourniquet.  
Palpates antecubital area to select venipuncture site.  
Properly cleanses venipuncture site.  
Rating Stars (Click) Sample Collection 1 2 3 4  
Stablizes vein.  
Inserts needle, bevel up.  
Smoothly pushes tube(s) into holder without changing needle position.  
Adjusts needle, if necessary, to obtain flow then stablizes vacutainer.  
Releases tourniquet as blood begins to flow.  
Changes vacutubes without changing needle position.  
Fills vacutubes in correct order.  
Mixes anticoagulated vacutubes properly.  
Removes last tube from needle before withdrawing needle.  
Withdraws needle from arm smoothly.  
Applies pressure to site after withdrawing needle.  
Disposes of needle properly and safely, Discards tourniquet.  
Rating Stars (Click) Handling & Processing 1 2 3 4  
Labels tubes immediately (ie at bedside).  
Legibly completes label/requisition with username and date/time of collection.  
Observe special handling requirements.  
Checks puncture site to ascertain bleeding has stopped. Applies bandage.  
Places tubes into biohazard bag. Label(s)/requisiton are placed in sleeve of bag.  
Removes gloves and practice hand hygiene.  
Transport specimens to lab via porter or pneumatic tube system. STATs are sent immediately.  
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Infant (Birth - 1 year)  
Preschooler (ages 2-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young Adults (ages 22-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)  
CERTIFICATIONS Other Expiry Date :  
Resource location – Lab Test information Guide.  
Blood Ethanol Collection – cleanse site with soap and water.  
Blood Culture Collection Review.