Phlebotomy Competency Assessment Form
Use this form to assess and document phlebotomy competency. Please complete all sections accurately.
Assessee Full Name
*
First Name
Last Name
Assessee Role
*
Please Select
Phlebotomist
Nurse
Medical Assistant
Other
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator Name
*
First Name
Last Name
Core Phlebotomy Competency Tasks
*
Rows
Needs Improvement
Meets Expectations
Exceeds Expectations
Patient identification and preparation
1
2
3
Hand hygiene and glove use
4
5
6
Venipuncture site selection
7
8
9
Blood collection technique
10
11
12
Specimen labeling and handling
13
14
15
Overall Competency Outcome
*
Competent
Requires Further Training
Not Competent
Post-Assessment Notes (concise summary)
Submit Assessment
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