Blood Transfusion Competency Assessment Form
Assess clinical competency in safe blood transfusion practices. Please complete all sections based on observed or demonstrated performance.
Full Name of Assessed Staff Member
*
First Name
Last Name
Role/Position
*
Please Select
Registered Nurse
Physician
Lab Technician
Other
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Knowledge of Blood Transfusion Protocols
*
1
2
3
4
5
Correct Patient Identification Prior to Transfusion
*
Always
Most of the time
Sometimes
Never
Pre-Transfusion Checks Completed
*
Yes, consistently
Partially
Not performed
Recognition and Management of Transfusion Reactions
*
Rows
Recognizes symptoms
Initiates appropriate response
Excellent
1
2
Good
3
4
Needs Improvement
5
6
Not Assessed
7
8
Adherence to Infection Control Procedures
*
1
2
3
4
5
Documentation of Transfusion in Patient Records
*
Accurate and complete
Incomplete
Not documented
Assessor Comments (if any)
Submit Assessment
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