Surgical Technologist Competency Checklist Form
Complete this competency checklist for a surgical technologist review. Use the exact same title consistently throughout the form.
Technologist Details
Technologist’s Full Name
*
First Name
Last Name
Department / Unit
*
Job Title / Role
*
Review Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Competency Checklist
Core Competencies Assessed
*
Preparation of sterile field
Instrument knowledge and setup
Aseptic technique
Specimen handling
Counts and verification
Operating room safety
Communication and team coordination
Other
Overall Competency Status
*
Competent
Needs Review
Not Observed
Comments / Areas for Improvement
Additional Notes
Evaluator Sign-Off
Evaluator Name
*
First Name
Last Name
Evaluator Signature
*
Submit
Submit
Should be Empty: