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F-QM-HR-002-A-V0 — Competency Assessment Record

Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.

Parent document: LAB-QM-HR-002 — Competency Assessment and Performance Evaluation Policy (parent is encoded in the form number)

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Document #	F-QM-HR-002-A-V0	Parent Document	LAB-QM-HR-002 — Competency Assessment Policy

1. Assessment Details

Field	Entry
Employee name	_______
Position / section(s) assessed	[ ] Medical Technologist [ ] Laboratory Aide
Assessment type	[ ] Initial (before independent work) [ ] Ongoing (annual) [ ] New procedure/analyzer [ ] Error-triggered [ ] Return after extended leave
Date(s) of assessment	_______
Assessor (name, role)	_______
Assessor independence confirmed (assessor does not evaluate own performance)	[ ] Yes

2. Test Systems / Tasks Assessed

#	Test System / Task / Instrument	Complexity	Assessed?
1	Automated Hematology (HORIBA Pentra XLR)	Moderate / High	[ ]
2	Wet Clinical Chemistry	Moderate / High	[ ]
3	Clinical Microscopy & Urinalysis	Moderate	[ ]
4	Rapid Serology (Dengue, HBsAg, Syphilis)	Waived / Moderate	[ ]
5	Specimen Accessioning & Rejection Verification	Routine Technical	[ ]

3. Required Competency Elements (6-Point Assessment)

#	Competency Element	Assessment Method	Result
3.1	Direct observation of routine patient test performance	Direct observation	[ ] Pass [ ] Fail
3.2	Monitoring recording and reporting of results (incl. critical results)	Audit of released results	[ ] Pass [ ] Fail
3.3	Review of worksheets, daily IQC records, and PT/EQAS surveys	Quality record review	[ ] Pass [ ] Fail
3.4	Instrument maintenance and routine calibration function checks	Practical demonstration	[ ] Pass [ ] Fail
3.5	Test performance using blind control or split-sample specimens	Blind replicate testing	[ ] Pass [ ] Fail
3.6	Problem-solving and out-of-control troubleshooting skills	Case scenario / interview	[ ] Pass [ ] Fail

4. Assessment Outcome

Field	Entry
Overall Percentage Score	_______ %
Competency Status	[ ] PASS (>= 75%) [ ] FAIL (< 75%)
Authorization Action	[ ] Grant Independent Authorization [ ] Maintain Current Authorization [ ] Suspend pending retraining

5. Corrective Retraining Plan (if FAIL)

Field	Entry
Identified Skill / Process Deficiency
Corrective Retraining Plan (Topic, Mentor, Schedule)
Reassessment Date and Target	Date: YYYY-MM-DD
Close-Out Verification	[ ] Reassessment Passed CMT Signature: __________________ Date: YYYY-MM-DD

6. Endorsement Signatures

Role	Name	Signature	Date
Assessor
Employee (acknowledges assessment results)
Chief Medical Technologist / Laboratory Quality Manager
Pathologist (final authorization and oversight)