Competency Assessment Form template
A form in the Personnel, Training and Competence procedure (PR12), mapped to ISO 15189:2022 clause 6.2. Fill it in whenever the task occurs. Used by the quality-management team.
FormISO 15189 · 6.2As needed
Calculated automaticallyRed = outside limits
Your LaboratoryCompetency Assessment Form | YL-QM-FRM-12-F08 v1.0
Record: Competency Assessment Form — October 2026
Staff nameR. Naidoo
PositionMedical Technologist
Task / examinationGlucose
SOP ref.REF-26-001
Assessor
Date2026-10-01
Assessment type
Next due2026-10-01
| No. | Criterion | Response | Evidence / comment |
|---|---|---|---|
| 1 | Follows the current version of the SOP | Met | Within limits |
| 2 | Identifies the patient and sample correctly | Met | |
| 3 | Prepares and handles reagents, calibrators and QC correctly | Met | |
| 4 | Performs and accepts or rejects QC correctly | Not met | Within limits |
| 5 | Operates and maintains the equipment correctly | Met | |
| 6 | Records and reports results accurately | Met | |
| 7 | Recognises and acts on critical results | Met | Within limits |
| 8 | Recognises problems and takes the correct action | Met | |
| 9 | Applies safety and PPE requirements | Met | |
| 10 | Completes records legibly and completely | Met | Within limits |
Blind / Previously Tested Samples
| No. | Sample ID | Expected result | Result obtained | Acceptable? |
|---|---|---|---|---|
| 1 | S26-1041 | 5 | 4.96 | Yes |
| 2 | S26-1048 | 4.91 | 4.97 | Yes |
| 3 | S26-1055 | 5.09 | 4.91 | Yes |
| 4 | S26-1062 | 4.91 | 4.94 | No |
| 5 | S26-1069 | 5.05 | 4.98 | Yes |
Outcome (competent / not yet competent)
Re-training plan
Sign-off
| Role | Name | Signature | Date |
|---|---|---|---|
| Staff member | |||
| Assessor |
Shaded cells are calculated automatically. Values in red are outside their limits. † marks a corrected value (see Corrections).
Controlled document. Printed copies are uncontrolled unless stamped.Page 1
A4 portrait · first page · showing 15 of 15 rowsExactly as LabToolkit Pro prints it — with your logo and colours
What it records
- Criterion
- Response
- Evidence / comment
- Sample ID
- Expected result
- Result obtained
- Acceptable?
Sign-off
- Staff member
- Assessor
Related templates
- Personnel File Checklist (PR12-F01)
- Personnel Orientation Checklist (PR12-F02)
- Code of Ethics, Impartiality & Confidentiality Declaration (PR12-F03)
- Personnel Training & Continuous Professional Development Plan (PR12-F04)
- Training Evaluation Form (PR12-F05)
- Competence Matrix (PR12-F06)
- General Competence Assessment Form (PR12-F07a)
- Management System Training and Competence Form (PR12-F07b)
- Departmental Technical Training and Competency Assessment (template for F07c–F07i) (PR12-F07c)
- Personnel Authorization Matrix (PR12-F09)
- Authorised Signatures & Initials Log (PR12-F10)
- Work Schedule (PR12-F11a)
- Departmental Duty Roster (PR12-F11b)
- On-call Roster (PR12-F11c)
- Personnel Replacement Form (PR12-F12)
- Guide: ISO 15189 documentation checklist
Clause references are to ISO 15189:2022; check them against your licensed copy of the standard.