Laboratory Competency Assessment Form 
Please fill out this form to evaluate and confirm the competency of laboratory personnel in performing essential tasks and procedures.
Part A: Pre-analytic
|  | Meets Standard | Does Not Meet Standard | N/A | Notes | 
|---|
| Sample Handling |  |  |  |  | 
| Sample Storage |  |  |  |  | 
| Laboratory Information Management System |  |  |  |  | 
Part B: Analytic
|  | Meets Standard | Does Not Meet Standard | N/A | Notes | 
|---|
| Sample Preparation |  |  |  |  | 
| Preventative maintenance logbook |  |  |  |  | 
| Instrument maintenance |  |  |  |  | 
| Function checks |  |  |  |  | 
| Intermediate test results |  |  |  |  | 
| Review and record test results |  |  |  |  | 
Part C: Post-analytic
|  | Meets Standard | Does Not Meet Standard | N/A | Notes | 
|---|
| Peer Review |  |  |  |  | 
| Final reporting of test results |  |  |  |  | 
| Sample management |  |  |  |  | 
| Test results documentation retention |  |  |  |  | 
| Validation or exercise data |  |  |  |  | 
| Quality improvement reports, case studies and/or scenarios |  |  |  |  | 
| Problem solving demonstration or quiz |  |  |  |  | 
                                                                
Assessor Signature
                                                 
                                                 Name:    
                                                 Date:      
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