Visual Urine Pregnancy Test Competency Assessment

Facility_________ Unit______________ Date__________________________

Name_________________________ Last 4 digits of SS#__________________

	Yes	No
Does kit have to be refrigerated?	□	□
Does kit have to be freshly opened?	□	□
How many drops of urine are necessary to run the test?	□ 2 drops	□ 3 drops
How long do you wait until to read results?	□ 2 min	□ 3 min
Can you report the results on a patient (line “S”) when the internal positive control line “C” does not appear?	□	□
Is the negative internal control indicated by the absence of interfering background in the result well?	□	□
Does the internal positive control have to be confirmed and documented with each patient?	□	□
Does the internal negative control have to be confirmed and documented with each patient?	□	□
Do you have to change Quality Control sheets if the kit’s lot # changes?	□	□
Do you repeat the test using a new kit if the internal positive and/or internal negative controls failed?	□	□
Evaluated by_____________________
To be completed by evaluator:
Did the operator accurately interpret results?	□	□
Is the operator overall competent?	□	□
Comments/Corrective Action: