Student Name: ________________________________ Student ID # : ______________________
Telephone # : ______________________
To the examining physician or nurse practitioner: As you complete this form, please consider the applicant’s physical ability
and behavioral characteristics. In doing so, please review carefully the General Job Description as you evaluate the
applicant’s ability to meet the Technical Standards specified for the health professions program that he/she is preparing to
enter. The College complies with the requirements and spirit of Section 504 of the Rehabilitation Act and the Americans with
Disabilities Act of 1990. Therefore, to the extent practical, the College will endeavor to make a reasonable accommodation
for an applicant with a disability who is otherwise qualified.
General Job Description: Phlebotomy technicians draw blood from patients and prepare specimens for testing or storage.
They work in hospitals, physicians’ offices, laboratories, clinics and blood banks. The phlebotomy technician must possess
excellent interpersonal skills, be capable of multiple tasking in a fast paced and at times high pressure environment.
Directions: Check the appropriate box for each of the following physical standards. All “No” responses require a written
explanation in the space provided below, and will be used by the College during its review for reasonable accommodation.
Frequency Key: O = Occasionally (1-33%) F=Frequently (34-66%) C=Constantly (67-100%)
Can the applicant perform the following physical actions listed in column one needed to perform the example(s)
listed in column two?
Physical Standards
Example
Frequency
Yes
No
LIFT
Lift supplies to replace, replenish, or store.
O
C
O
F
C
C
C
C
C
O
F
O
C
C
C
BEND OR
STOOP/CROUCH
To perform phlebotomy on patients who are
sitting or in a recumbent position
To store or access supplies
KNEEL/STAND
For computer usage, filing
To perform Phlebotomy
MOVE
Torso, arms, hands and fingers to demonstrate
dexterity.
REACH
Obtain supplies, patient samples, or procedure
manuals
WEAR
Personal Protective Equipment and gloves for an
extended period of time
MANUAL
DEXTERITY
Perform phlebotomy
Prepare slides to view
Computer usage
PUSH/PULL
To move equipment, tables, chairs or patients.
WALK/STAND
For extended periods of time, up to 12 hours
AUDITORY
To hear various alarms
Hear colleagues, other health care professionals
and patients including the ability to communicate
via telephone
TECHNICAL STANDARDS
for
HEALTHCARE TECHNICIAN
Revised
04/19
Physical
Standards
Example
Frequency
Yes
No
VISUAL
Determine specimen acceptability by viewing tube top color
and quantity of specimen obtained.
C
To check equipment for proper function.
C
Read small print on vacutainers, needles and other similar
supplies.
C
Assess and confirm proper labeling of specimens
C
Read patient requisitions
C
To assess patient condition; monitor patient safety and
comfort
C
FINE MOTOR
SKILLS
Perform phlebotomy
C
Ability to perform capillary punctures effectively and
efficiently
F
Ability to manipulate phlebotomy equipment effectively
C
Ability to properly apply labels to specimens.
C
Ability to hold and use a writing instrument for recording
pertinent information.
C
TACTILE
Palpate veins for venipuncture
C
C
Perform Phlebotomy
VERBAL
Communicates effectively to colleagues, patients and other
health care providers.
C
Behavioral Standards: In your professional opinion, can the applicant be responsible for the following behavior(s)?
Function safely, effectively, and calmly under stressful conditions?
C
Maintain composure while managing multiple tasks simultaneously?
C
Exhibit social skills necessary to interact effectively and respectfully with
patients, families, supervisors, and co-workers of the same or different
cultures?
C
Maintain personal hygiene consistent with close personal contact associated
with patient care, and working in close proximity to co-workers?
C
Provide an explanation for any “No” answers: _________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
STUDENT SIGNATURE
I have reviewed these Technical Standards and I understand
the physical abilities and behavioral characteristics necessary
to complete this program. I am responsible to notify my
program coordinator of any changes in my status.
Signature of Student Date
PRINT of Student Name
HEALTH CARE AGENT SIGNATURE
_____________________________________________
______________________________________________
I certify that to the best of my knowledge, the above
assessment is accurate and was performed within twelve
months from anticipated start of educational program.
Signature of Physician, PA-C, or NP Date
_________________________________________
____________________________________________
PRINT of Physician, PA-C, or NP name.
Revised
04/19
RETURN THIS FORM TO:
Northern Essex Community College
Division of Health Professions
414 Common Street
Lawrence, MA 01840
Fax: 978-655-5934
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