<p> University of Texas Medical Branch School of Health Professions – Department of Clinical Laboratory Sciences Galveston, Texas 77555-1140</p><p>Preceptorship Performance Evaluation</p><p>To be completed by the student:</p><p>Student Name: </p><p>Section of Laboratory Microbiology and Serology/Immunology </p><p>Institution </p><p>Dates of Training ______To be completed by the supervisor of the student:</p><p>Name of student’s supervisor: </p><p>Institution and Division: ______Purpose The UTMB CLS student is required to meet cognitive (knowledge), psychomotor (skill) and affective (attitude) objectives of each preceptorship. This document outlines the cognitive and psychomotor objectives of the program. Cognitive goals are evaluated through the use of a quiz based on the study guide questions, which are based on these preceptorship objectives. This quiz is given by UTMB. The following objectives can be used as a checklist for what to have the student perform and/or to discuss or show the student. You, as the supervisor of the student, should initial those items you have discussed with the student, had the student observe or the student was able to perform. </p><p>Preceptorship Objectives SPECIMEN PROCESSING 1. apply the established procedures for obtaining or receiving specimens, including examination of requisitions and logging in of specimens 2. differentiate between appropriate specimens for processing and those that should be rejected, including reason for the choice 3. identify and integrate reasons for choice of the appropriate media, atmospheric conditions, temperature, and length of incubation for culturing various types of specimens 4. explain and demonstrate the proper sterile and inoculation techniques for isolation of micro- organisms 5. compare media selected for the cultures, whether standard, enriched, differential, or selective and identify what the medium contains and why it is used 6. demonstrate and explain universal precautions in handling bio-hazardous materials 7. appraise hazards that may be encountered and prevented 8. choose appropriate specimens for anaerobic cultures 9. assess correct methods for culture and transport of anaerobic specimens 10. assess correct collection and handling of samples for virology cultures/testing DIRECT TESTING CONCEPTS AND PROCEDURES 1. interpret and compare results of direct gram stain procedures, including cellular and bacterial morphology, and blood culture stains 2. interpret and evaluate results of sputum screens for culture, including the purpose of these screens 3. interpret and evaluate rapid strep screens, including types of internal and external positive and </p><p>Revised 05/2010 1 negative controls 4. interpret and evaluate rapid antigen tests with correct and incorrect control results 5. interpret and evaluate EIA and IFA direct testing methods 6. compare the principles of the gram stain, rapid strep screen, rapid antigen tests, EIA and IFA, and sputum screening procedures 7. state the principle of nucleic acid probe testing for venereal diseases 8. given a laboratory situation requiring screening tests, select the appropriate test to be performed IDENTIFICATION OF AEROBIC AND ANAEROBIC ORGANISMS 1. compare principles of basic, standard procedures for identification of known gram positive and gram negative organisms 2. evaluate methods used to isolate organisms in multiple organism cultures to obtain pure cultures 3. evaluate aerobic cultures and determine what constitute normal flora and potential pathogens from various sources and types of specimens 4. examine and compare the significance of bacterial colonies on primary plating media and describe appearance and hemolytic patterns on blood agar and appearance on MacConkey agar 5. select, perform, and give the principle of tests needed for identification of isolated organisms, based upon colonies observed on primary plating media 6. perform and evaluate methods of colony counts and identification procedures on urine cultures and explain the significance of results obtained 7. discuss the importance of reporting the isolation and identification of clinically significant organisms to the proper professional(s) 8. compare and contrast different systems for achieving anaerobic conditions 9. evaluate the appearance of colonies growing anaerobically on media used for primary isolation of anaerobes, and select appropriate identification testing 10. compare methods used for the identification of anaerobes 11. identify anaerobes that are considered endogenous and/or pathogenic by body site 12. select appropriate identification techniques for Clostridium difficile. ANTIMICROBIAL SUSCEPTIBILITY STUDIES 1. use CLSI guidelines on susceptibility testing to ensure compliance 2. compare disk diffusion, MIC, and MBC methods for susceptibility testing 3. select appropriate method for susceptibility testing considering type and origin of organism 4. observe, perform, and evaluate results of automated methods for susceptibility testing 5. evaluate causes of development of antibiotic resistance 6. evaluate mechanisms of antibiotic action on the bacteria 7. evaluate antibiotic susceptibility and appropriate reporting of susceptibility testing for infections caused by specific types of organisms QUALITY CONTROL AND QUALITY ASSURANCE 1. perform and report results of quality control 2. use CLSI guidelines for quality control in microbiology to determine compliance 3. apply quality assessment programs to ensure the validity of tests 4. perform, report, and evaluate preventive maintenance of instruments 5. detect instrument malfunctions and take appropriate action MYCOBACTERIOLOGY 1. describe the principle and perform concentration-digestion and decontamination methods for acid-fast organisms 2. choose appropriate media, incubation conditions, and length of time for growth of the commonly occurring mycobacteria 3. compare acid-fast (such as Kinyoun) and fluorescent staining techniques 4. perform and interpret acid-fast and/or fluorescent staining for Mycobacteria 5. compare grouping of Mycobacteria other than tuberculosis (MOTT) and tuberculosis to determine relationships PARASITOLOGY 1. state the principle of formalin/ethyl acetate concentration method for specimen processing and explain sources of error and limitations 2. design a proper collection technique for pinworms to optimize recovery of the organism 3. demonstrate calibration of ocular micrometer for production of conversion chart for sizing Revised 05/2010 2 parasites 4. discuss two concentration procedures to prepare a specimen for ova and parasite examination; including which organisms may not be identifiable by each method 5. discuss and interpret wet preps or pictures of such preps for Ova and Parasites 6. discuss and interpret smears or pictures of such smears for blood and tissue parasites 7. discuss and interpret special stains for Cryptosporidium and Cyclospora 8. compare and contrast staining procedures for malaria and other parasites found in blood or body fluids 9. select quality control, quality assurance and preventive maintenance procedures to ensure the validity of tests 10. given pictures, slides, or other representations of trophozoites, cysts and/or ova, correctly identify the organism 11. differentiate and identify specific nematode infections based on clinical symptoms and laboratory findings 12. differentiate and identify specific cestode infections based on clinical symptoms and laboratory findings 13. differentiate and identify specific trematode infections based on clinical symptoms and laboratory findings 14. differentiate and identify protozoan infections based on clinical symptoms and laboratory findings MYCOLOGY 1. differentiate between contaminant and pathogenic fungi by examining fungal cultures 2. identify fungi in slide culture, wet preps, LPCB preparations or from other representations 3. compare commercial yeast identification methods 4. identify and state the principle of basic tests used to identify fungi and yeasts VIROLOGY 1. apply established procedures for obtaining or receiving specimens, including examination of requisitions and logging in of specimens 2. differentiate between appropriate specimens for processing and those that should be rejected, including reason for the choice 3. identify and integrate reasons for choice of the appropriate media, atmospheric conditions, temperature, and length of incubation for culturing various types of specimens 4. compare principles of basic, standard procedures for identification of common viruses 5. differentiate and identify specific viruses based on cytopathic effects SEROLOGY/IMMUNOLOGY PRECEPTORSHIP OBJECTIVES Preceptorship Objectives GENERAL PROCEDURES 1. Apply established procedures for obtaining or receiving specimens, including examination of requisitions and logging in of specimens 2. Differentiate between appropriate specimens for processing and those that should be rejected, including reason for the choice 3. Perform and report results of quality control 4. Process specimens for send out to a reference laboratory</p><p>ANALYSIS 5. Perform, interpret and evaluate rapid agglutination tests, including types of internal and external positive and negative controls 6. Interpret and evaluate infectious mononucleosis tests 7. Interpret and evaluate enzyme immunoassay testing methods 8. Interpret and evaluate immunofluorescence testing methods 9. Interpret and evaluate chemiluminescence testing methods 10. Interpret and evaluate Western blot assays</p><p>Revised 05/2010 3 Scale: 3 = exceeds entry level requirements (>80%) – produces work of high quality 2 = Meets entry level requirements (70%) – requires little duplication of instruction and makes few errors 1 = does not meet entry level requirements (<70%) - improvement needed. </p><p>) ) y</p><p> l l r s</p><p>Criteria: please circle the box which you feel represents this % % e e t t 0 0 v v n n 8 7 e e e e ( l student’s ability during and/or after this preceptorship rotation. l</p><p>></p><p> t ( s m y ) y e t e s r r e n t r t t % i e n n n m 0 u e e e m 7</p><p> q T s e s m < e t r ( d e O i e R e r</p><p> e u i N l e</p><p> q u e c s M e v x q e r e e o E l R D</p><p>Technical Knowledge and Competence 1. Recalled the scientific principles of laboratory test procedures 3 2 1 2. Discussed technical and procedural concepts 3 2 1 3. Detected the need for and used problem solving procedures 3 2 1 4. Integrated and practiced safety regulations 3 2 1 5. Explained the principles of quality assurance and quality control 3 2 1 6. Discussed scientific information and the application of principles 3 2 1 as they related to tests performed/sent to reference lab by this area. 7. Recognized abnormal laboratory data and made correlations with 3 2 1 associated pathology 8. Confirmed the validity of test results and selected additional test 3 2 1 procedures 9. Performed and interpreted diagnostic tests with accuracy 3 2 1 10. Used quality control procedures 3 2 1 11. Calibrated instruments or determined QC requirements for 3 2 1 instruments. 12. Evaluated computer generated data 3 2 1 13. Effectively analyzed malfunctions and trouble shoots instruments 3 2 1 and/or procedures 14. Selected appropriate samples and test methods 3 2 1 15. Selected appropriate reagents/ blood products and instruments. 3 2 1 16. Evaluated laboratory Data 3 2 1</p><p>Revised 05/2010 4 Please indicate your appraisal of the individual’s performance as a clinical laboratory science professional by checking one box:</p><p>EXCELLENT [ ] Average [ ] Below Average [ ]</p><p>Please provide examples of any marks of “Does not meet entry level Requirements” level 1 and/or any other comments you would like to make about this student: </p><p>Supervisor: Please sign below. Thank you for you appraisal of this student’s experience at your facility.</p><p>Signature: Date: </p><p>This evaluation may be given to the student to give to the Education Coordinator at UTMB or you may mail or fax:</p><p>University of Texas Medical Branch School of Health Professions Clinical Laboratory Sciences Department Preceptorship Coordinator 301 University Blvd Galveston, Texas 77555-1140</p><p>Fax: 409-772-9470</p><p>Revised 05/2010 5</p>