Kavherine MKSARU Name of Immunizing Learner (Please print)

Improving medication use. Advancing patient care.
APhA's Injection Technique Assessment Form
This is an exercise in documentation - be sure to complete in entirety
Katherine Mkparu Name of Immunizing Learner (Please print)
Name of Immunizing Learner (Please print)
Florence Mkparu
Date
MonthDayYear
04/-1/2021
12/13/2020
Faculty Evaluation When administering an injection, the participant should demonstrate all of the following: 60 Inserts needle to hub in smooth motion Uses appropriate syringe size Uses appropriate needle gauge Activates safety mechanism appropriately Uses appropriate needle length Disposes syringe in sharps container immediately Selects proper injection site Provides proper injection site care Prepares injection site properly Maintains a clean and sterile work space Stabilizes patient during injection Documents injection appropriately (see below) Holds syringe appropriately
Withdraws needle appropriately
VIS
12/19/20Nml saline 12/13/20Nml Saline 12/13/20Nml Saline
04-310-KK
04-310-DKHospira 04-310-DKHospira
0.5MCIMRIDelt4/01/202012/18/2020 Hospira 0.5mcRTPert4/01/2020 12/13/2020 0.5mlS.Q12/13/2020 RTAm
BACKGEN
8/15/19
FLORENCE MKPARU
Recipient's Name (Injection Assessment Partner / person whose arm was used) (Please
Recipient's Name(Injection Assessment Partner / person whose arm was used)(Please Print) FinDan Signature of Injection Recipient n
Signature of Injection Recipient
Date
MonthDayYear
Date
12/13/2020
Signature of Immunizing Learner (Person giving Immunizations)
Pharmacist
Title
To be completed after injection technique - Signature below signifies that the individual above performed the injection techniques in your presence.
Participant needs additional training
Technique is acceptable, learner is ready to immunize patients
Assessor Signature
for
Jennif- yyhar Assessor (Print Name, include title and license number)
Assessor (Print Name, include title and license number)
Date
MonthDayYear
Date
NPI #
APhA's Injection Technique Assessment Form © 2020, American Pharmacists Association. All rights reserved.
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APhA's Injection Technique Assessment Form

Katherine Mkparu Name of Immunizing Learner (Please print)

12/13/2020

VIS

04-310-KK

04-310-DKHospira 04-310-DKHospira

BACKGEN

8/15/19

FLORENCE MKPARU

Recipient's Name(Injection Assessment Partner / person whose arm was used)(Please Print) FinDan Signature of Injection Recipient n

12/13/2020

Pharmacist

for