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									                                               Policy # MI\ORIEN\v08            Page 1 of 2
                       Microbiology Department
Policy & Procedure Manual
Section: Orientation for Technologists and     Subject Title: Table of Contents
        Technicians
Issued by: LABORATORY MANAGER                  Original Date: July 3, 2002
Approved by: Laboratory Director               Revision Date: March 06, 2008
                                               Review Date: May 31, 2011

                   ORIENTATION FOR TECHNOLOGISTS AND TECHNICIANS
                                 TABLE OF CONTENTS

WELCOME TO THE UHN/MSH DEPARTMENT OF MICROBIOLOGY ........................ 3
WEEK 1 - 23 ONWARD .............................................................................................................. 6
  WEEK ONE ................................................................................................................................ 6
  WEEKS TWO AND THREE ..................................................................................................... 8
  WEEKS FOUR TO SEVEN (TECHNOLOGISTS ONLY) ...................................................... 8
  WEEKS EIGHT TO ELEVEN ................................................................................................. 8
  WEEKS TWELVE TO FIFTEEN ............................................................................................ 8
  PROBATIONARY PERIOD REVIEW ..................................................................................... 9
  WEEKS SIXTEEN TO NINETEEN .......................................................................................... 9
  WEEKS TWENTY-TO TWENTY FIVE .................................................................................. 9
  WEEK TWENTY SIX ONWARDS .......................................................................................... 9
DEPARTMENT STRUCTURE & CULTURE-DIRECTOR OR MANAGER ................... 10
DEPARTMENTAL ISSUES-CHARGE TECHNOLOGIST ................................................. 11
DEPARTMENTAL SAFETY ISSUES - SAFETY TECHNOLOGIST / INFECTION
CONTROL PRACTITIONER .................................................................................................. 12
INFORMATION SYSTEMS TRAINING................................................................................ 14
PLANTING & ACCESSIONING ............................................................................................. 15
  Accessioning Bench .................................................................................................................. 15
  Urine and Respiratory Planting Bench ..................................................................................... 16
  Infection Control and Genital Tract Culture Bench .................................................................. 17
  Miscellaneous Planting Bench .................................................................................................. 18
  Send-out Bench ......................................................................................................................... 19
  Outstanding List Review by Send-out Bench and Miscellaneous Planting Bench .................. 20
RESPIRATORY BENCH .......................................................................................................... 21
URINE BENCH .......................................................................................................................... 23
MISCELLANEOUS / WOUND BENCH ................................................................................. 24
GYNAE & ENTERICS BENCH ............................................................................................... 26
BLOOD CULTURE.................................................................................................................... 28
INFECTION CONTROL BENCH ........................................................................................... 31
VITEK BENCH .......................................................................................................................... 33
AXSYM BENCH ......................................................................................................................... 34
C. difficile BENCH ...................................................................................................................... 36
EBV BENCH ............................................................................................................................... 37
HTLV 1/2 BENCH ...................................................................................................................... 38
Molecular BENCH ...................................................................................................................... 39
Mono BENCH ............................................................................................................................. 41
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UHN\MSH Microbiology Department                                        Policy # MI\ORIEN\v08                               Page 2 of 2
Policy & Procedure Manual
Section: Orientation for Technologists and                             Subject Title: Table of Contents
        Technicians

VZ Ab BENCH ............................................................................................................................ 42
WNV IgG & IgM BENCH ......................................................................................................... 43
Virology Planting BENCH ......................................................................................................... 44
Virology Shell Vial BENCH ....................................................................................................... 45
Virology Tube Culture BENCH ................................................................................................ 47
Roche Light Cycler PCR BENCH ............................................................................................ 50
MYCOLOGY BENCH ............................................................................................................... 52
Quality Control Bench................................................................................................................ 55
QUALITY MANAGEMENT SYSTEM TRAINING .............................................................. 56
Record of Edited Revisions .......................................................................................................... 57




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                                                       Policy # MI\ORIEN\01\v04        Page 1 of 3
                       Microbiology Department
Policy & Procedure Manual
Section: Orientation for Technologists                 Subject Title: Welcome to the UHN/MSH
              Manual                                          Department of Microbiology
Issued by: LABORATORY MANAGER                          Original Date: July 3, 2002
Approved by: Laboratory Director                       Revision Date:
                                                       Review Date: May 31, 2011

        WELCOME TO THE UHN/MSH DEPARTMENT OF MICROBIOLOGY

As the Director of the Department of Microbiology I am pleased to welcome you to our team.
This document will provide you with some information about the department and act as a guide
throughout your orientation. This process will ensure that all new employees will have a fair and
comprehensive orientation to the department.

I will be meeting with you at various milestones throughout your orientation to review your
progress and to share any concerns or suggestions that you may have with the process.

All of the components of this program have been designed by the department’s staff for you and
as such represent those points considered by your peers to be the most critical for your success.

I hope that you enjoy the process and that you and the Department of Microbiology will have a
long and successful journey together.


Best Wishes
Martin Skulnick
Administrative Director


Why we’re all here…..

The UHN/ MSH Department of Microbiology is recognized as the leading academic, service and
reference laboratory in the country. Our team is comprised of a diverse group of professionals
dedicated to providing exemplary laboratory services to our patients, and to advancing laboratory
science. In striving for this mission the team’s work is guided by the values of:
 Service quality
 Academic excellence
 Innovation
 Accountability




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And our culture is guided by:
 Diversity and respect for all
 Enthusiasm and life long learning
 Teamwork

How you can make your orientation experience the very best it can be…
The UHN/MSH Department of Microbiology is no ordinary operation - in fact we think we are
the laboratory to work for in Canada. One of the key benefits to working here is access to leading
edge laboratory practice and knowledge. Your work experience here is largely dependent on
what you make it. We will supply the tools for you, but ultimately you will need to become
involved in departmental activities, committees and projects to enjoy the full experience.

Who are we?…
The Joint Department of Microbiology is a partnership of the UNIVERSITY HEALTH
NETWORK and the Mount Sinai Hospital. It is located on two sites: Bacteriology at MSH and
Virology, Serology, Parasitology and Mycology at the St. Patrick’s site.

We service in excess of 5000 beds in our core hospitals and client institutions. These include:
University Health Network (Toronto General, Toronto Western, Princess Margaret)
Mount Sinai Hospital
Ajax/Pickering (Rouge Valley Health System)
Centenary Health Centre (Rouge Valley Health System)
Baycrest Centre for Geriatric Care
Riverdale Hospital
Toronto Grace Hospital
Canadian Addiction and Mental Health
Rehabilitation Institute of Toronto (4 locations)
Other programs include:
Bone bank, Eye bank, M.O.R.E program, Cord Blood Program

The Department of Microbiology is comprised of a diverse group of dedicated and talented
health care professionals and support staff.




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In 2002 the Microbiology Team is comprised of around 100 persons who are either directly
involved with patient care or with research:
 52 Technologists
 14 Technicians
 6 Medical Staff
 8 Management, Support and Clerical Staff
 4 Infection Control Staff
 15-20 Research Staff

Every member of the Microbiology Team is expected to contribute to a work environment that
supports our mission and equally supports diversity and respect in the workplace.

What do we do…
The department offers a full range of services to our clients: Bacteriology, Virology, Serology,
Parasitology and Mycology.

The department processes in excess of 330,000 specimens annually:

Specimen Type         Percent of Total
Bacteriology                 52
Serology/Virology            18
Infection Control            20
Mycology                      2
Parasitology                  1
Others                        7


We are part of a much larger group…
Although you will be part of the Microbiology Team, you are part of a much larger family. The
other laboratories at UHN and MSH have an additional 800 staff members, 500 at UHN and 300
at MSH. As an employee of Microbiology you are fortunate, in that you will have the benefits
that come with belonging to both groups. You will be presented with the opportunity to enhance
your education, to experience the rewards of committee participation as well as partaking in
various social events throughout the year.




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                                                    Policy # MI\ORIEN\02\v04       Page 1 of 4
                       Microbiology Department
Policy & Procedure Manual
Section: Orientation for Technologists              Subject Title: Week 1 - 23 Onward
              Manual
Issued by: LABORATORY MANAGER                       Original Date: July 3, 2002
Approved by: Laboratory Director                    Revision Date:
                                                    Review Date: May 31, 2011

                                 WEEK 1 - 23 ONWARD

WEEK ONE

1.    Introductions
      On arrival, the new employee will report to the Director or Manager. A formal
      introduction to the Director, Manager, Charge Technologists, Dr. Low and the other
      medical microbiologists will take place. During a departmental tour, the remaining
      Microbiology staff will be introduced.

2.    Tour Of Both Sites
      The new employee will tour both sites with the Director or Manager. They will be shown
      the locations of the washrooms, food refrigerators, Infection Control, cafeteria, La
      Baguette, Occupational Health and Human Resources. Rules for using public areas such
      as the classroom, library and staff lounge (St. Patrick's site) will also be discussed.

3.    Meeting With Director/Manager
      The new employee will meet with the Director or Manager and discuss the following:
       An explanation of the Joint Department
       Departmental orientation process
       Organizational chart
         Patient Confidentiality Policy
         Diversity and respect for others
         Who to go to for what
         Shift structure, coffee and lunch breaks
         Vacation Policy
         Attendance Management and Workplace Injuries
         Continuing education opportunities, conferences and rounds
         Orientation process and probationary period

      The employee and Manager will document that they discussed the above.




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                     Microbiology Department
Policy & Procedure Manual
Orientation For Technologists Manual


4.     Meeting with Charge Technologist
       The new employee will meet with a Charge Technologist and discuss the following:
        Manuals
        Telephone and Critical Values Policy
        Schedules, notice boards
        Location and use of internal forms
        Lockers, keys etc
        Departmental cultural issues (expectations around helping others, etc)
        Supplies/Ordering

       The employee and Charge Technologist will document that they have discussed the
       above. The documentation is to be given to the Director and filed in the employee’s
       record.

5.     Meeting with Safety Representative and Infection Control
       The employee will meet with the safety representative and discuss the following:
        Universal Precautions
        What to do in case of fire
        Emergency codes system
        WHMIS
        Lab coat policy/shoes

       The employee and safety representative will document that they have discussed the
       above. The documentation is to be given to the Director.

6.     Information Systems Training
       The new employee will receive an introduction and training from a Laboratory
       Information System (LIS) Officer or key operator in the following:
        SCC (SoftMic, SoftLab, SoftQC and SoftStore modules)
        Ulticare/Vista
           Cerner
           Website

The training will include exercises that involve strategies to deal with commonly seen problems
such as correcting reports. The new employee will not proceed to any further training on the
benches until they have demonstrated the necessary skills to the trainer.

The Director will meet with the employee at the end of the first week to review progress and
answer any questions that they may have.

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Policy & Procedure Manual
Orientation For Technologists and Technicians


                                    TRAINING SCHEDULE


WEEKS TWO AND THREE

If the employee has demonstrated the required proficiency in week one, they will proceed to the
planting/accessioning area. The purpose of this rotation is to better familiarize the employee
with the complexity of the department and reinforce the computer skills learned in week one.
Technologists will be teamed with the Senior Technologist for the first week and then work
independently. Technicians will be teamed with an experienced technician who is familiar with
the duties of the area until their training is complete.

The employee will meet with the Director and the trainer at the end of week three to review
progress.

WEEKS FOUR TO SEVEN (TECHNOLOGISTS ONLY)

If the employee has satisfied the training objectives of the previous two weeks they will be
scheduled on the Respiratory Bench. The first two weeks will be in tandem with a teaching
technologist, the third and fourth week will be solo. This session will also include training on
the operational procedures of the Vitek.

The employee will meet with the Director and the trainer at the end of week seven to review
progress. The employee will not move to the next bench until they have proven their
competency in this area.

WEEKS EIGHT TO ELEVEN

If the employee has satisfied the training objectives of the previous section they will be
scheduled on the Urine Bench. The first two weeks will be in tandem with the teaching
technologist and the third and fourth week will be solo.

The employee will meet with the Director and the trainer at the end of week 11 to review
progress.

WEEKS TWELVE TO FIFTEEN

If the employee has satisfied the training objectives of the previous section they will be
scheduled on the Miscellaneous/Wound Bench. The first two weeks will be in tandem with the
teaching technologist, and the third and fourth weeks will be solo.

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Policy & Procedure Manual
Orientation For Technologists and Technicians

The employee will meet with the Director and the trainer at the end of week fifteen to review
progress.


PROBATIONARY PERIOD REVIEW

The employee’s performance will be reviewed after the preliminary fifteen-week rotation. If the
employee has met the training objectives and demonstrated an acceptable level of proficiency the
Director will issue a letter confirming this. If the employee has failed to meet the objectives or
demonstrate the required proficiency the Director will meet with the employee and either extend
the probationary period or terminate the employee.

If the employee has passed the probation period they will then proceed through the other benches
as outlined below.


WEEKS SIXTEEN TO NINETEEN

If the employee has satisfied the training objectives of the previous section they will be
scheduled on the Gynae and Enteric Bench. The first two weeks will be in tandem with the
teaching technologist and the third and fourth week will be solo.

The employee will meet with the Director and the trainer at the end of week 19 to review
progress.


WEEKS TWENTY-TO TWENTY FIVE

Blood Culture Bench. At completion of the six weeks the employee will review their time on the
bench with the trainer and Charge Technologist.


WEEK TWENTY SIX ONWARDS

From here the employee will be scheduled onto the Infection Control and Quality Control
benches. After completion of these benches the employee will complete a 4-week repetition of
all benches before being scheduled at the St. Patrick’s site for Virology, Serology, Mycology and
Parasitology.




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Policy & Procedure Manual
Section: Orientation For Technologists                      Subject Title: Department Structure &
       Manual                                               Culture-Director or Manager
Issued by: LABORATORY MANAGER                               Original Date: July 3, 2002
Approved by: Laboratory Director                            Revision Date:
                                                            Review Date: May 31, 2011


       DEPARTMENT STRUCTURE & CULTURE-DIRECTOR OR MANAGER


1. Department Structure and Culture-Director or Manager

                Area/Competency                      Employee     Date     Director     Date
                                                     Signature            Signature
1.1   Employee understands the structure of
      the Joint Department (organizational
      chart, committees and responsibilities)
1.2   Is familiar with the departmental
      orientation process and probationary
      period
1.3   Is familiar with the shift structure and
      expectations around coffee and lunch
      breaks
1.4   Is familiar with the vacation policy
1.5   Is familiar with the hospital’s
      attendance management program
1.6   Is familiar with security issues and the
      name tag policy
1.7   Is aware of the policy concerning
      diversity and respect for others
1.8   Is aware of the policy concerning
      continuing education, conferences and
      rounds




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                      Microbiology Department          MI\ORIEN\03\02\v04
Policy & Procedure Manual
Section: Orientation For Technologists                 Subject Title: Departmental Issues-
       Manual                                          Charge Technologist
Issued by: LABORATORY MANAGER                          Original Date: July 3, 2002
Approved by: Laboratory Director                       Revision Date:
                                                       Review Date: May 13, 2011


               DEPARTMENTAL ISSUES-CHARGE TECHNOLOGIST


2. Departmental Issues-Charge Technologist

               Area/Competency                   Employee     Date      Charge        Date
                                                 Signature            Technologist
                                                                       Signature
2.1   Employee understands format of
      manuals and where they are located
2.2   Telephone Policy and etiquette has
      been explained
2.3   Employee is aware of the critical
      values policy
2.4   Employee has been given a locker and
      security pass
2.5   Employee has been shown the location
      of notice boards and work schedules
2.6   Departmental cultural issues i.e.,
      expectations around helping others,
      reporting to Charge Technologist if
      scheduled as a float.
2.7   Payroll Issues
2.8   Supplies




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Section: Orientation For Technologists                   Subject Title: Departmental Safety Issues -
              Manual                                                    Safety Technologist/Infection
                                                                        Control Practitioner
Issued by: LABORATORY MANAGER                            Original Date: July 3, 2002
Approved by: Laboratory Director                         Revision Date:
                                                         Review Date: May 31, 2011


      DEPARTMENTAL SAFETY ISSUES - SAFETY TECHNOLOGIST / INFECTION
                       CONTROL PRACTITIONER


3.    Departmental Safety Issues- Safety Technologist/Infection Control Practitioner

                Area/Competency                 Employee          Date       Safety       Date
                                                Signature                 Officer/ICP
                                                                           Signature
3.1     Employee has read the Safety
        Manual and reviewed it with the
        Safety Officer
3.2     Employee has met with Infection
        Control Practitioner and is aware of
        policies regarding Body Substance
        Precautions and Needle Stick
        Injuries
3.3     Employee has reviewed fire safety
        issues:
        Nature of fire alarm
        Location of pull stations
        Location and types of extinguishers
        Location of fire blanket
        Departmental evacuation
        procedures
        REACT/RACE
        Phone 5555
3.4     Employee has reviewed emergency
        codes
3.5     Employee has reviewed WHMIS
        and location of MSDS sheets
3.6     Employee has reviewed appropriate
        Personal Protective Equipment



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               Area/Competency                Employee        Date      Safety       Date
                                              Signature              Officer/ICP
                                                                      Signature
3.7    Employee has reviewed Spill
       Policy to include chemical and
       biological spills and spill kits
3.8    Employee has reviewed appropriate
       disinfection and disposal practices
3.9    Employee has reviewed proper use
       and location of the following:
       Biological safety cabinets
       Centrifuges
       Eye Wash
       Emergency Showers
3.10   Employee has reviewed safe
       laboratory practices to include
       reduction of aerosols
3.11   Employee has reviewed workplace
       ergonomic issues to include:
       Workstation design
       Lifting to avoid back injury
3.12   Employee has reviewed location
       and hours of Occupational Health
3.13   Employee has reviewed location of
       MSH Emergency Department for
       first aid




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                      Microbiology Department           MI\ORIEN\03\04\v04
Policy & Procedure Manual
Section: Orientation For Technologists                  Subject Title: Information Systems
       Manual                                           Training
Issued by: LABORATORY MANAGER                           Original Date: July 3, 2002
Approved by: Laboratory Director                        Revision Date:
                                                        Review Date: May 31, 2011

                        INFORMATION SYSTEMS TRAINING

4. Information Systems Training

               Area/Competency                  Employee       Date      Trainer      Date
                                                Signature               Signature
4.1    Review the LIS manual and Soft
       Computer Company (SCC)
       manuals with the trainer
4.2    Review of security policies for all
       information systems and security
       access provided to the network, LIS
       and Ulticare/Vista
4.3    Overview of HIS systems/clients
       including integration with LIS
       through interfaces
4.4    Introduction to Meditech and
       Cerner Hospital Information
       System (HIS) systems
4.5    Introduction and training on
       Ulticare/Vista
4.6    Introduction and training on
       SoftComm
4.7    Introduction and preliminary
       training on SoftMic and
       SoftMicQC
4.8    Introduction and preliminary
       training on SoftLab and SoftQC
4.9    Introduction and preliminary
       training on SoftStore
4.10   Introduction to the Microbiology
       website and on-line manual
4.11   Review of downtime policies
4.12   Label and report printer training
4.13   Introduction to LIS support policies


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Policy & Procedure Manual
Section: Orientation for Technologists                  Subject Title: Planting and Accessioning
              Manual
Issued by: LABORATORY MANAGER                           Original Date: July 3, 2002
Approved by: Laboratory Director                        Revision Date: March 6, 2008
                                                        Review Date: May 31, 2011

                              PLANTING & ACCESSIONING
5. Planting and Accessioning
                   Area/Competency                     Employee     Date      Trainer      Date
                                                       Signature             Signature
Accessioning Bench:
5.1.1 Has reviewed the manual section
        with the trainer
5.1.2 Validates information according to
        requisition, specimen and accepts/rejects
        specimen based on Specimen
        Acceptance Policy
5.1.2 Accessions specimen using manual and
        computerized methods as appropriate
5.1.3 Understands how to order entry using
        Soft and Misys
5.1.4 Understand how to order entry for
        different specimens for different
        hospitals:
         UHN (TGH, TWD & PMH)
         Rouge Valley (CHC & APH)
         Toronto Grace Hospital
         Bridgepoint Hospital
         MSH
         Baycrest Hospital
         TRI
         CAMH
         Referred-in specimens (Note: the
            difference between each)
5.1.5 Determines processing requirements
        during downtime
5.1.6 Know where to pick up specimens from
        MSH 6th floor when required
5.1.7 Understand how to sort specimens
5.1.8 Knowledge of appropriate media for
        different types of specimens
5.1.9 Know which specimens to send out to
        the appropriate location
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                  Area/Competency                     Employee    Date    Trainer    Date
                                                      Signature          Signature
Urine and Respiratory Planting Bench:
5.2.1 Knowledge of specimen collection,
       transportation and proper containers
5.2.2 Evaluates the suitability of specimens
       and acts in accordance with policy (not
       sufficient quantity, leaking specimen,
       unlabelled specimen, wrong container
       and when to pool etc.)
5.2.3 Knowledge of preparation and staining
       of different kinds of smears e.g. gram,
       eosinophils, ZN, Fungal
5.2.4 Knowledge of appropriate media for
       different types of specimen i.e. media
       types, composition, and purpose
5.2.5 Knowledge of processing and planting
       different types of specimens i.e. urine,
       sputum, BAL, bronchial brushes, etc.
5.2.6 Knowledge of condition for incubating
       primary isolation media
5.2.7 Knows how to process specimens using
       cytospin, centrifuges, grinders,
       stomacher, InocuLab, Isoplater and
       Gram Stain Instrument
5.2.8 QC set up for Isoplater and Biosafety
       cabinet settle plates
5.2.9 QC recording for Biosafety cabinets,
       Bench cleaning and Biosafety cabinet
       settle plate sterility.
5.2.10 Knowledge of operating the Translogic
5.2.11 Knowledge of operating the Cytospin
5.2.12 Knowledge of maintenance and
       troubleshooting InocuLab, Isoplater and
       Gram Stain Instrument
5.2.13 Knowledge of what media to stock up
5.2.14 Storage of specimens before and after
       processing and is aware of Retention
       Time Policies
5.2.15 Familiar with the proper daily
       disinfection of the work area
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                 Area/Competency                 Employee    Date     Trainer     Date
                                                 Signature           Signature
Infection Control and Genital Tract Culture Bench:
5.3.1 Knowledge of specimen collection,
        transportation and proper containers for
        Infection Control and Gential Tract
        cultures
5.3.2 Knowledge of appropriate media for
        different infection control specimens
        and genital specimens
5.3.3 Knowledge of processing and planting
        infection control specimens
        (MRSA,VRE, ESBL etc.), and genital
        specimens (vag screen, GBS, Cervical
        and urethral)
5.3.4 Knowledge of condition for incubating
        primary isolation media for infection
        control and genital specimens.
5.3.5 Knows how to process specimens using
        InocuLab, Isoplater and Gram Stain
        Instrument
5.3.6 QC set up for Biosafety cabinet settle
        plates
5.3.7 QC recording for Biosafety cabinets,
        Bench cleaning and Biosafety cabinet
        settle plate sterility.
5.3.8 Knowledge of operating the Translogic
5.3.9 Knowledge of maintenance and
        troubleshooting InocuLab, Isoplater and
        Gram Stain Instrument
5.3.10 Knowledge of what media to stock up
5.3.11 Storage of specimens before and after
        processing and is aware of Retention
        Time Policies
5.3.12 Familiar with the proper daily
        disinfection of the work area




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#                 Area/Competency                     Employee    Date    Trainer    Date
                                                      Signature          Signature
Miscellaneous Planting Bench:
5.4.1 Knowledge of specimen collection,
        transportation and proper containers
5.4.2 Knowledge of preparation and staining
        of different kinds of smears e.g. grams,
        ZN, modified Kinyoun stain and Fungal
        stain.
5.4.3 Knowledge of appropriate media for
        different types of specimen (media
        types, composition, purpose advantages
        and disadvantage)
5.4.4 Knowledge of processing and planting
        different types of specimens i.e. swabs,
        fluids, pus, tissues, bone marrow,
        biopsies, nails, skin scrapings, etc.)
5.4.5 Knowledge of condition for incubating
        primary isolation media
5.4.6 Knows how to process specimens using
        Isoplater and Gram Stain Instrument
5.4.7 QC set up for Biosafety cabinet settle
        plates.
5.4.8 QC recording for Biosafety cabinets,
        Bench cleaning and Biosafety cabinet
        settle plate sterility.
5.4.9 Knowledge of operating the Translogic
5.4.10 Knowledge of maintenance and
        troubleshooting Isoplater and Gram
        Stain Instrument
5.4.11 Knowledge of what media to stock up
5.4.12 Storage of specimens before and after
        processing and is aware of Retention
        Time Policies
5.4.13 Familiar with the proper daily
        disinfection of the work area
5.4.14 After 2 pm, becomes a floater. Stock up
        buckets and bench with media. Do
        stains. Unload Isoplater and separate
        plates and help where needed.


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        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 18
                                                         Policy #              Page 5 of 6
                     Microbiology Department             MI\ORIEN\03\05\v05
Policy & Procedure Manual
Orientation For Technologists Manual

#                 Area/Competency                     Employee    Date    Trainer    Date
                                                      Signature          Signature
Send-out Bench:
5.5.1 Employee is familiar with sending
       specimens for Mycobacteria testing to
       the Public Health Lab as outlined in the
       manual
5.5.2 Employee is familiar with sending
       specimens for Parasitology testing to the
       Public Health Lab as outlined in the
       manual
5.5.3 Employee is familiar with sending
       specimens for Legionella, Mycoplasma,
       Chlamydia culture testing to the Public
       Health Lab as outlined in the manual
5.5.4 Employee is familiar with sending
       specimens for antigen testing to MIRA
       VISTA Diagnostics as outlined in the
       manual
5.5.5 Employee is familiar with sending
       specimens for slit skin smear for
       Leprosy to National Hansen’s Disease
       Programs as outline in the manual
5.5.6 Employee is familiar with entering
       negative results for Mycobacteria,
       parasitology, Legionella, Mycoplasma,
       Clamydia culture testing from the Public
       Health Lab as outlined in the manual




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 19
                                                  Policy #                 Page 6 of 6
                     Microbiology Department      MI\ORIEN\03\05\v05
Policy & Procedure Manual
Orientation For Technologists Manual

#                Area/Competency                  Employee  Date     Trainer      Date
                                                  Signature         Signature
Outstanding List Review by Send-out Bench and Miscellaneous Planting Bench:
5.6.1 Employee is familiar with daily printing,
       checking, resutling and documentation
       of Outstanding Receiving Worklist for
       Bacteriology and Infection Control.
5.6.2 Employee is familiar with daily printing
       of Plating Worklist and resolve
       outstanding unplated orders.
5.6.3 Employee is familiar with daily
       checking of CHC, Ajax and Baycrest
       Receiving Worklist and identify
       outstanding orders against manifest lists.




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                        Page 20
                                                             Policy #                      Page 1 of 2
                        Microbiology Department              MI\ORIEN\03\06\v04
Policy & Procedure Manual
Section: Orientation for Technologists                       Subject Title: Respiratory Bench
       Manual
Issued by: LABORATORY MANAGER                                Original Date: July 3, 2002
Approved by: Laboratory Director                             Revision Date:
                                                             Review Date: May 31, 2011

                                   RESPIRATORY BENCH

6. Respiratory Bench

                  Area/Competency                        Employee     Date      Trainer        Date
                                                         Signature             Signature
6.1    The employee has reviewed the manual
       with the trainer
6.2    Employee is familiar with the proper
       reading and reporting of Gram stains
       and wet preparations
6.3    Employee is familiar with the policy
       concerning the rejection criteria of
       sputum specimens
6.4    Employee is familiar with the protocol
       for quantitation of cultures
6.5     Employee is familiar with the culture
       media and reagents used in this section
6.6    Employee is familiar with the common
       respiratory pathogens:
       Streptococcus pneumoniae
       Haemophilus influenzae
       Streptococcus pyogenes
       Pseudomonas aeruginosa
       Enterobacteriaceae species
       Neisseria meningitidis
6.7    Employee is familiar with the following
       procedures:
       ALA, Germ Tube, Cefinase,
       Cetrimide, MRSA panel, Denka,
       Gen-Probe
6.8    Employee is familiar with procedures
       used for identifying and performing
       susceptibility tests on significant isolates




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                               Page 21
                                                            Policy #             Page 2 of 2
                     Microbiology Department                MI\ORIEN\03\06\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                 Area/Competency                      Employee    Date    Trainer     Date
                                                       Signature          Signature
6.9    Employee has demonstrated the ability
       to generate appropriate and accurate
       reports in accordance with the
       laboratory manual
6.10   Employee is familiar with the policy
       concerning the work up of yeasts and
       the referral of moulds to mycology
6.11   Employee is familiar with the policy
       concerning notification of Infection
       Control and the phoning of critical value
       results
6.12   Employee has demonstrated the ability
       to perform QC testing associated with
       the bench and is able to enter the results
       into MicQC
6.13   Employee has demonstrated the ability
       to enter isolates into the SoftStore
       program
6.14   Employee is familiar with the proper
       daily disinfection of the work area
6.15   Other duties include:
       Reading grams
       Preparing Vitek saline tubes
       Answering the phone




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 22
                                                         Policy #                      Page 1 of 1
                      Microbiology Department            MI\ORIEN\03\07\v04
Policy & Procedure Manual
Section: Orientation For Technologists                   Subject Title: Urine Bench
       Manual
Issued by: LABORATORY MANAGER                            Original Date: July 3, 2002
Approved by: Laboratory Director                         Revision Date:
                                                         Review Date: May 13, 2011

                                       URINE BENCH
7. Urine Bench

                  Area/Competency                      Employee     Date      Trainer      Date
                                                       Signature             Signature
7.1  Employee has reviewed the manual with
     the trainer
7.2 Employee is familiar with the culture
     media and reagents used in the section
7.3 Employee is familiar with the significance
     of the urine colony counts
7.4 Employee is familiar with procedures used
     for identifying and performing
     susceptibility tests on significant isolates
7.5 Employee has demonstrated the ability to
     enter results into the LIS using batch entry
7.6 Employee has demonstrated the ability to
     generate appropriate and accurate reports
     in accordance with the laboratory manual
7.7 Employee is familiar with the policy
     concerning notification of Infection
     Control and the phoning of critical value
     results
7.8 Employee has demonstrated the ability to
     perform QC testing associated with the
     bench and is able to enter the results into
     MicQC
7.9 Employee has demonstrated the ability to
     enter isolates into the SoftStore program
7.10 Employee is familiar with the proper daily
     disinfection of the work area
7.11 Other duties include:
     Reading grams
     Preparing Vitek saline tubes
     Answering the phone



                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 23
                                                        Policy #                    Page 1 of 2
                      Microbiology Department           MI\ORIEN\03\08\v04
Policy & Procedure Manual
Section: Orientation For Technologists                  Subject Title: Miscellaneous / Wound
       Manual                                           Bench
Issued by: LABORATORY MANAGER                           Original Date: July 3, 2002
Approved by: Laboratory Director                        Revision Date:
                                                        Review Date: May 31, 2011

                          MISCELLANEOUS / WOUND BENCH

                 Area/Competency                      Employee    Date      Trainer     Date
                                                      Signature            Signature
8.1  Employee has reviewed the manual with
     the trainer
8.2 Employee is familiar with the correct
     incubation times and atmospheres for each
     type of medium and specimen
8.3 Employee is familiar with the workflow
     routines and work lists
8.4 Employee is familiar with the proper use
     and maintenance of the anaerobic holding
     tank
8.5 Employee is familiar with the proper use
     of the anaerobic jars, and QC
     documentation of the biological controls
8.6 Employee is familiar with the policies
     concerning the work up and reporting of
     anaerobes
8.7 Employee is familiar with the appropriate
     use of susceptibility tests as specified in
     the manual for each client/specimen
8.8 Employee has demonstrated the ability to
     generate appropriate and accurate reports
     in accordance with the laboratory manual
8.9 Employee is familiar with the proper
     practice for the set up and incubation of
     the oxacillin and vancomycin screen and
     high level aminoglycoside plates
8.10 Employee is familiar with the procedure
     to refer isolates to PHL and referral of
     yeast and moulds to mycology




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 24
                                                       Policy #                Page 2 of 2
                     Microbiology Department           MI\ORIEN\03\08\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                Area/Competency                      Employee    Date    Trainer    Date
                                                      Signature          Signature
8.11 Employee is familiar with the policy
     concerning notification of Infection
     Control and the phoning of critical value
     results
8.12 Employee has demonstrated the ability to
     perform QC testing associated with the
     bench and is able to enter the results into
     MicQC
8.13 Employee has demonstrated the ability to
     enter isolates into the SoftStore program
8.14 Employee is familiar with the proper daily
     disinfection of the work area
8.15 Other duties include:
     Reading grams
     Preparing Vitek saline tubes
     Answering the phone




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 25
                                                          Policy #                      Page 1 of 2
                      Microbiology Department             MI\ORIEN\03\09\v04
Policy & Procedure Manual
Section: Orientation For Technologists                    Subject Title: Gynae & Enterics Bench
       Manual
Issued by: LABORATORY MANAGER                             Original Date: July 3, 2002
Approved by: Laboratory Director                          Revision Date:
                                                          Review Date: May 31, 2011

                               GYNAE & ENTERICS BENCH

9. Gynae and Enterics Bench

                  Area/Competency                       Employee     Date      Trainer      Date
                                                        Signature             Signature
9.1   Employee has reviewed the manual with
      the trainer
9.2   Employee is familiar with the proper
      procedure for interpreting and reporting
      of gram stains and wet preps
9.3   Employee is familiar with the culture
      media, appropriate incubation times and
      conditions and reagents used in the section
9.4   Employee is familiar with the colonial
      morphology of the pathogens encountered
      on this bench
9.5   Employee is familiar with the criteria for
      setting up identification and susceptibility
      tests
9.6   Employee has demonstrated the ability to
      enter results into the LIS using batch entry
9.7   Employee is familiar with the procedure
      for performing serological tests on isolates
9.8   Employee is familiar with the procedure
      for performing the following:
      API NHI card, Gonogen, TSI,
      ONPG-PAM, Urea, TSB
9.9   Employee has demonstrated the ability to
      generate appropriate and accurate reports
      in accordance with the laboratory manual




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                              Page 26
                                                       Policy #                Page 2 of 2
                     Microbiology Department           MI\ORIEN\03\09\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                Area/Competency                      Employee    Date    Trainer    Date
                                                      Signature          Signature
9.10 Employee is familiar with the procedure
     to refer isolates to PHL and referral of
     yeast and moulds to mycology
9.11 Employee is familiar with the policy
     concerning notification of Infection
     Control and the phoning of critical value
     results
9.12 Employee has demonstrated the ability to
     perform QC testing associated with the
     bench and is able to enter the results into
     MicQC
9.13 Employee has demonstrated the ability to
     enter isolates into the SoftStore program
9.14 Employee is familiar with the proper daily
     disinfection of the work area
9.15 Other duties include:
     Reading grams
     Preparing Vitek saline tubes
     Answering the phone




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 27
                                                             Policy #                      Page 1 of 3
                      Microbiology Department                MI\ORIEN\03\10\v04
Policy & Procedure Manual
Section: Orientation For Technologists                       Subject Title: Blood Culture
       Manual
Issued by: LABORATORY MANAGER                                Original Date: July 3, 2002
Approved by: Laboratory Director                             Revision Date:
                                                             Review Date: May 31, 2011

                                       BLOOD CULTURE

10.    Blood Culture

                    Area/Competency                      Employee     Date    Trainer          Date
                                                         Signature            Signature
10.1      Employee has reviewed the manual
          with the trainer
10.2      Employee is familiar with the principle
          of the BacT/Alert instrument and blood
          culture bottle media
10.3      Employee is familiar with Lysis
          centrifugation method (i.e., Isolator 10)
10.4      Employee is familiar with the proper
          procedure for processing specimens
          incubated off-line
10.5      Employee is familiar with the proper
          procedure for testing and reporting
          requests for:
          SBE/IE, PUO/FUO
          Dimorphic fungus
          Cryptococcus
           Brucella
          Bone marrow
          Bone bank
          Sterile fluids
10.6      Employee is familiar with the daily
          operations of the BacT/Alert including
          maintenance and troubleshooting
10.7      Employee is familiar with the
          procedure for accessioning bottles into
          the hospital data system (HDS),
          laboratory information system (LIS)
          and BacT/Alert system




                                     PROCEDURE MANUAL
         UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                               Page 28
                                                            Policy #             Page 2 of 3
                     Microbiology Department                MI\ORIEN\03\10\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                 Area/Competency                       Employee    Date    Trainer    Date
                                                        Signature          Signature
10.8    Employee is familiar with the proper
        procedure for loading bottles including
        the use of generic bottle barcode labels
10.9    Employee is familiar with the process
        for unloading, processing and reporting
        positive bottles
10.10   Employee is familiar with the process
        for reloading false positive bottles
10.11   Employee is familiar with the process
        for unloading and reporting negative
        bottles
10.12   Employee is familiar with the
        procedure for downtime of the
        BacT/Alert instrument
10.13   Employee is familiar with the culture
        media, incubation times and reagents
        used in the section
10.14   Employee is familiar with the
        appropriate use of susceptibility tests as
        specified in the manual for each
        client/specimen
10.15   Employee has demonstrated the ability
        to generate appropriate and accurate
        reports in accordance with the
        laboratory manual
10.16   Employee is familiar with the
        procedure to refer isolates to PHL and
        referral of yeast and moulds to
        mycology
10.17   Employee is familiar with the policy
        concerning notification of Infection
        Control and the phoning of critical
        value results to ward/physician/
        Infectious Disease resident




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                              Page 29
                                                      Policy #               Page 3 of 3
                     Microbiology Department          MI\ORIEN\03\10\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                 Area/Competency                   Employee    Date    Trainer    Date
                                                    Signature          Signature
10.18   Employee has demonstrated the ability
        to perform QC testing associated with
        the bench and is able to enter the
        results into MicQC
10.19   Employee has demonstrated the ability
        to enter isolates into the SoftStore
        program
10.20   Employee is familiar with the proper
        daily disinfection of the work area
10.21   Other duties include:
        Reading grams
        Preparing Vitek saline tubes
        Answering the phone




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                          Page 30
                                                        Policy #                      Page 1 of 2
                       Microbiology Department          MI\ORIEN\03\11\v04
Policy & Procedure Manual
Section: Orientation for Technologists                  Subject Title: Infection Control Bench
       Manual
Issued by: LABORATORY MANAGER                           Original Date: July 3, 2002
Approved by: Laboratory Director                        Revision Date:
                                                        Review Date: May 31, 2011


                              INFECTION CONTROL BENCH

11. Infection Control Bench

                  Area/Competency                     Employee     Date      Trainer      Date
                                                      Signature             Signature
11.1    Employee has reviewed the manual
        with the trainer
11.2    Employee is familiar with the design of
        the media, incubation requirements and
        colonial morphology of significant
        isolates on selective media used on the
        bench
11.3    Employee is familiar with the work up
        of new MRSA and VRE
11.4    Employee is familiar with the work up
        of previous positive MRSA and VRE
11.5    Employee is familiar with the
        identification tests used on the bench:
        Tube coagulase, Gen-Probe, PYR dry
        slide test, Rapid xylose, Sugars for
        enterococcal identification
11.6    Employee is familiar with the work up
        of ESBLs and MROs
11.7    Employee is familiar with and
        understands the significance and
        reporting of:
        Oxacillin screen plate, Mupirocin E
        test, ESBL testing, MIC panels




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 31
                                                            Policy #             Page 2 of 2
                     Microbiology Department                MI\ORIEN\03\11\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                 Area/Competency                       Employee    Date    Trainer    Date
                                                        Signature          Signature
11.8    Employee is familiar with the
        appropriate use of susceptibility tests as
        specified in the manual for each
        client/specimen
11.9    Employee is familiar with the procedure
        to refer isolates to PHL and referral of
        yeast and moulds to mycology
11.10   Employee is familiar with the policy
        concerning notification of Infection
        Control and the phoning of critical
        value results
11.11   Employee has demonstrated the ability
        to perform QC testing associated with
        the bench and is able to enter the results
        into MicQC
11.12   Employee has demonstrated the ability
        to enter isolates into the SoftStore
        program
11.13   Employee is familiar with the proper
        daily disinfection of the work area
11.14   Other duties include:
        Reading grams
        Preparing Vitek saline tubes
        Answering the phone




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                              Page 32
                                                           Policy #                 Page 1 of 1
                      Microbiology Department              MI\ORIEN\03\12\v04
Policy & Procedure Manual
Section: Orientation For Technologists                     Subject Title: Vitek Bench
       Manual
Issued by: LABORATORY MANAGER                              Original Date: July 3, 2002
Approved by: Laboratory Director                           Revision Date:
                                                           Review Date: June 16, 2008


                                      VITEK BENCH

12. Vitek Bench


                  Area/Competency                     Employee    Date      Trainer      Date
                                                      Signature            Signature
12.1    Employee has reviewed the Vitek
        manual with the trainer
12.2    Employee is familiar with system
        overview
12.3    Employee is familiar with card set-up
12.4    Employee is familiar with daily start-up
        and QC
12.5    Employee is familiar with problem
        solving




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 33
                                                         Policy #                     Page 1 of 2
                      Microbiology Department            MI\ORIEN\03\14\v04
Policy & Procedure Manual
Section: Orientation/Training for                        Subject Title: <AXSYM> Bench
        Technologists/Technician Manual                                 Training Checklist
Issued by: LABORATORY MANAGER                            Original Date:
Approved by: Laboratory Director                         Revision Date:
                                                         Review Date: May 31, 2011

                                       AXSYM BENCH

                  Area/Competency                      Employee     Date      Trainer        Date
                                                       Signature             Signature
14.1   The trainee has reviewed safety aspects
       including:
       a. The features of a Biosafety
       Containment 2 Lab.
       b. Virus Material Safety Data Sheet
       (MSDS).
       c. Operation of a Biosafety Cabinet.
       d. Use of disinfectants and waste disposal.
14.2   The trainee has reviewed the Serology
       Procedure Manual relating to the testing
       of all the hepatitis markers using the
       AXSYM.
14.3   The trainee has reviewed the Serology
       Procedure Manual relating to the
       procedures of performing the daily,
       weekly and monthly maintenance on
       AXSYM.
14.4   The trainee has reviewed the Serology
       Procedure Manual relating to which and
       when to run each of the external controls.
14.5   The trainee has reviewed the Serology
       Procedure Manual relating to how and
       when to post certain results.
14.6   The trainee has reviewed the Serology
       Procedure Manual relating to looking up
       previous hepatitis results in Vista.
14.7   The trainee has reviewed the Serology
       Procedure Manual relating to performing
       the HBsAg Confirmation Assay.




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 34
                                                         Policy #              Page 2 of 2
                     Microbiology Department             MI\ORIEN\03\14\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                 Area/Competency                     Employee    Date    Trainer    Date
                                                      Signature          Signature
14.8  The trainee has reviewed the Serology
      Procedure Manual relating to the weekly
      checking of the supplies according to the
      inventory list.
14.9 The trainee has reviewed the Serology
      Procedure Manual relating to
      documenting the ‘rec’d date’ and ‘in-use
      date’ with each reagent kit, controls kit
      and calibrators.
14.10 The trainee has reviewed the Serology
      Procedure Manual relating to ‘Pending
      List’.




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 35
                                                              Policy #                 Page 1 of 1
                      Microbiology Department                 MI\ORIEN\03\15\v04
Policy & Procedure Manual
Section: Orientation/Training for                             Subject Title: C. difficile Bench
        Technologists/Technician Manual                                      Training Checklist
Issued by: LABORATORY MANAGER                                 Original Date:
Approved by: Laboratory Director                              Revision Date:
                                                              Review Date: May 31, 2011

                                       C. difficile BENCH

                  Area/Competency                       Employee    Date       Trainer      Date
                                                        Signature             Signature
15.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of disinfectants and waste disposal.
15.2 The trainee has reviewed the Serology
     Procedure Manual relating to the
     preparation of stool specimens for testing.
15.3 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of the Behring 2000,including daily and
     weekly maintenances.
15.4 The trainee has reviewed the Serology
     Procedure Manual relating to
     interpretation and reporting of C.difficile
     results, including calling positive result(s)
     to ward and Infection Control.
15.5 The trainee has reviewed the Serology
     Procedure Manual relating to the
     performing of external QC testing: with
     each new lot of kit.




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                              Page 36
                                                           Policy #                 Page 1 of 1
                      Microbiology Department              MI\ORIEN\03\16\v04
Policy & Procedure Manual
Section: Orientation/Training for                          Subject Title: <EBV> Bench Training
        Technologists/Technician Manual                                   Checklist
Issued by: LABORATORY MANAGER                              Original Date:
Approved by: Laboratory Director                           Revision Date:
                                                           Review Date: May 31, 2011

                                        EBV BENCH

                  Area/Competency                      Employee    Date      Trainer    Date
                                                       Signature            Signature
16.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of disinfectants and waste disposal.
16.2 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of the Behring 2000,including daily and
     weekly maintenances.
16.3 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of external QC testing: with each new lot
     of kit.

16.4 The trainee has reviewed the Serology
     Procedure Manual relating to the
     interpretation and reporting of EBV
     results.




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 37
                                                          Policy #                   Page 1 of 1
                      Microbiology Department             MI\ORIEN\03\17\v04
Policy & Procedure Manual
Section: Orientation/Training for                         Subject Title: <Eye Banks Bench>
        Technologists/Technician Manual                                  Bench Training Checklist
Issued by: LABORATORY MANAGER                             Original Date:
Approved by: Laboratory Director                          Revision Date:
                                                          Review Date: May 31, 2011

                                     HTLV 1/2 BENCH

                  Area/Competency                     Employee     Date      Trainer      Date
                                                      Signature             Signature
17.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of disinfectants and waste disposal.
17.2 The trainee has reviewed the Serology
     Procedure Manual relating to the
     procedures of running Biorad HBsAg and
     HIV ½ EIA testing and HTLV ½ EIA
     testing using the P-Lab.
17.3 The trainee has reviewed the Serology
     Procedure Manual relating to the STAT
     testing of specimens from Eye Banks.
17.4 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of external QC (Accurun 5100 ).

17.5 The trainee has reviewed the Serology
     Procedure Manual relating the
     interpretation and reporting of HBsAg
     and HIV ½ results.
17.6 The trainee has reviewed the Serology
     Procedure Manual relating the
     interpretation and reporting of HTLV ½
     results.

17.7 The trainee has reviewed the Serology
     Procedure Manual relating the running of
     external QC (Virotrol 1).

                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 38
                                                           Policy #                   Page 1 of 2
                      Microbiology Department              MI\ORIEN\03\18\v04
Policy & Procedure Manual
Section: Orientation/Training for                          Subject Title: <Molecular> Bench
        Technologists/Technician Manual                                   Training Checklist
Issued by: LABORATORY MANAGER                              Original Date:
Approved by: Laboratory Director                           Revision Date:
                                                           Review Date: May 31, 2011

                                     Molecular BENCH

                  Area/Competency                      Employee     Date      Trainer     Date
                                                       Signature             Signature
18.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of disinfectants and waste disposal.
18.2 The trainee has reviewed the Serology
     Procedure Manual relating to the
     procedures of using the MagNA Pure to
     extract HCV RNA, including weekly and
     monthly maintenance.
18.3 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of the COBAS to detect HCV RNA,
     including weekly and monthly
     maintenances.
18.4 The trainee has reviewed the Serology
     Procedure Manual relating to the
     interpretation and reporting of the
     qualitative HCV RNA PCR result.
18.5 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of external QC testing: Accurun 325
     monthly.

18.6 The trainee has reviewed the Serology
     Procedure Manual relating to the
     Extracting procedure for HBV DNA.




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 39
                                                        Policy #                   Page 2 of 2
                      Microbiology Department           MI\ORIEN\03\18\v04
Policy & Procedure Manual
Section: Orientation/Training for                       Subject Title: <Molecular> Bench
        Technologists/Technician Manual                                Training Checklist

#                 Area/Competency                    Employee     Date      Trainer         Date
                                                     Signature             Signature
18.7   The trainee has reviewed the Serology
       Procedure Manual relating to the running
       of the COBAS to detect HBV DNA,
       including weekly and monthly
       maintenance.
18.8   The trainee has reviewed the Serology
       Procedure Manual relating to the
       interpretation and reporting of the
       qualitative HBV DNA PCR result.
18.9   The trainee has reviewed the Serology
       Procedure Manual relating to the running
       of external QC: Accurun 300 and 600 in
       each run.

18.10 The trainee has reviewed the Serology
      Procedure Manual relating to the
      Chlamydia/GC PCR testing using BD
      ProbeTec®, including maintenances and
      the running of external QC(Accurun 341).

18.11 The trainee has reviewed the Serology
      Procedure Manual relating to the
      interpretation and reporting of positive
      CT/GC results, including calling all
      positive result to physician/ward List’.
18.12 The trainee has reviewed the Serology
      Procedure Manual relating to ‘Pending
      List’.
18.13 The trainee has reviewed the Serology
      Procedure Manual relating to weekly
      checking of supplies using the inventory
      list.
18.14




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                           Page 40
                                                        Policy #                   Page 1 of 1
                      Microbiology Department           MI\ORIEN\03\19\v04
Policy & Procedure Manual
Section: Orientation/Training for                       Subject Title: <Mono> Bench Training
        Technologists/Technician Manual                                Checklist
Issued by: LABORATORY MANAGER                           Original Date:
Approved by: Laboratory Director                        Revision Date:
                                                        Review Date: May 31, 2011

                                        Mono BENCH

                  Area/Competency                     Employee    Date     Trainer     Date
                                                      Signature           Signature
19.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of disinfectants and waste disposal.
19.2 The trainee has reviewed the Serology
     Procedure Manual relating to the
     procedures of using the Monospot Kit.
19.3 The trainee has reviewed the Serology
     Procedure Manual relating to the
     interpretation and reporting of results,
     including calling all positive to
     physician/ward.
19.4 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of external QC testing (Accurun 31) with
     each new lot of kit.

19.5




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 41
                                                            Policy #                 Page 1 of 1
                      Microbiology Department               MI\ORIEN\03\20\v04
Policy & Procedure Manual
Section: Orientation/Training for                           Subject Title: <VZ Ab> Bench Training
        Technologists/Technician Manual                                    Checklist
Issued by: LABORATORY MANAGER                               Original Date:
Approved by: Laboratory Director                            Revision Date:
                                                            Review Date: May 31, 2011

                                         VZ Ab BENCH

                  Area/Competency                       Employee    Date      Trainer     Date
                                                        Signature            Signature
20.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of disinfectants and waste disposal.
20.2 The trainee has reviewed the Serology
     Procedure Manual relating to the
     procedures of using the Varicella
     Antibody Kit and the VIDAS.
20.3 The trainee has reviewed the Serology
     Procedure Manual relating to
     interpretation and reporting of VZ Ab
     results, including calling positive result(s)
     to ward and Infection Control.
20.4 The trainee has reviewed the Serology
     Procedure Manual relating to the
     performing of external QC testing with
     each new lot of kit.

20.5




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                              Page 42
                                                        Policy #                 Page 1 of 1
                      Microbiology Department           MI\ORIEN\03\21\v04
Policy & Procedure Manual
Section: Orientation/Training for                       Subject Title: <WNV IgG & IgM> Bench
        Technologists/Technician Manual                                Training Checklist
Issued by: LABORATORY MANAGER                           Original Date:
Approved by: Laboratory Director                        Revision Date:
                                                        Review Date: May 31, 2011

                                 WNV IgG & IgM BENCH

                  Area/Competency                     Employee    Date    Trainer    Date
                                                      Signature          Signature
21.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of disinfectants and waste disposal.
21.2 The trainee has reviewed the Serology
     Procedure Manual relating to the using of
     Washer and Syva Spectrophotometer
     reader
21.3 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of the Behring 2000,including daily and
     weekly maintenances.
21.4 The trainee has reviewed the Serology
     Procedure Manual relating to the
     interpretation and reporting of WNV IgG
     and IgM results.
21.5 The trainee has reviewed the Serology
     Procedure Manual relating to the running
     of the external QC testing ( Accurun
     165)with each new lot of kit.




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 43
                                                          Policy #                    Page 1 of 1
                      Microbiology Department             MI\ORIEN\03\22\v04
Policy & Procedure Manual
Section: Orientation/Training for                         Subject Title: <Virology Planting>
        Technologists/Technician Manual                                  Bench Training Checklist
Issued by: LABORATORY MANAGER                             Original Date:
Approved by: Laboratory Director                          Revision Date:
                                                          Review Date: May 31, 2011

                                  Virology Planting BENCH

                  Area/Competency                      Employee     Date      Trainer     Date
                                                       Signature             Signature
22.1 The trainee has reviewed safety aspects
     including:
     a. The limits of a Biosafety Containment 2
     Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a 2-person Biosafety
     Cabinet.
     d. Use of centrifuge Safety Cups.
     d. Proper attire (gloves and front closed
     gown).
     e. Use of disinfectants, recycling cytoclips
     and waste disposal.
22.2 The trainee has reviewed the Virology
     Procedure Manual including:
     a. The Specimen-Cell Line planting chart.
     b. Preparation of Direct Smears using
     double cytospin preparations.
     c. Shell Vials (MRC-5).
     d. Tissue Tube Cultures (CMK; HEp-2;
     HFF; RD).
22.3 The trainee is familiar with ordering tests
     using:
     a. Soft Lab Information System.
     b. Vista.
22.4




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 44
                                                           Policy #                   Page 1 of 2
                      Microbiology Department              MI\ORIEN\03\23\v04
Policy & Procedure Manual
Section: Orientation/Training for                          Subject Title: < Virology Shell Vial>
        Technologists/Technician Manual                                   Bench Training
                                                                          Checklist
Issued by: LABORATORY MANAGER                              Original Date:
Approved by: Laboratory Director                           Revision Date:
                                                           Review Date: May 31, 2011

                                 Virology Shell Vial BENCH

                  Area/Competency                     Employee     Date       Trainer      Date
                                                      Signature              Signature
23.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a Biosafety Cabinet.
     d. Use of centrifuge Safety Cups.
     d. Use of a needle for the Shell Vial
     Procedure.
     e. Use of disinfectants and waste disposal.
23.2 The trainee has reviewed the Virology
     Procedure Manual relating to Direct
     Smears including:
     a. Preparation, staining, reading,
     interpretation and reporting of Direct
     Smears including different schemes and
     scenarios for SimulFuor Resp Screen
     panel, fluA/B panel, RSV/Para3 panel and
     the Para2,3/Adeno panel
23.3 The trainee has reviewed the Virology
     Procedure Manual relating to Shell Vials
     staining, reading, interpretation and
     reporting.
23.4 The trainee has reviewed the Virology
     Procedure Manual relating to Direct
     Smear and Shell Vial Quality Controls
     and is familiar with entering these results
     in the LIS and/or the QC book and to
     inform the senior/charge of out of range
     results.


                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                            Page 45
                                                        Policy #               Page 2 of 2
                     Microbiology Department            MI\ORIEN\03\23v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                   Area/Competency                     Employee    Date     Trainer    Date
                                                        Signature           Signature
23.5  The trainee has reviewed the LIS Inventory
      Registration, the inventory list and the
      ordering binder.
23.6 The trainee is familiar with the procedures
      for lot change including:
      a. Inactivating old reagent lot in the LIS.
      b. Activating the new lot in the LIS.
      c. Performing appropriate QC on all
      components of the reagent (eg. for Resp
      Screen, all 7 respiratory viruses).
23.7 The trainee has reviewed the reading of
      positive Direct Smears for
      a. Herpes simplex
      b. VZ
      c. Respiratory viruses
23.8 The trainee has reviewed the reading of
      positive Shell Vials for:
      a. Herpes simplex and/or VZ
      b. CMV
23.9 The trainee has reviewed the limitations and
      sources of errors for Direct Smears
      including:
      a. Number of cells needed.
      b. Contaminating positive cells from another
      slide when sharing wash buffer.
23.10 The trainee has reviewed the limitations and
      sources of errors for Shell Vials including:
      a. Toxicity on monolayer.
      b. Flipping of coverslip when washing.
23.11 The trainee is familiar with reporting positive
      results including:
      a. Entering "F7 isolate" in the LIS to enable
      tracking.
      b. Phoning the ward/Dr. with certain results.
      c. Informing Infection Control with certain
      results (eg. VZ, respiratory virus).
      d. Reporting to LCDC the number of
      respiratory viruses detected as well as the
      total number performed.

                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 46
                                                          Policy #                    Page 1 of 3
                      Microbiology Department             MI\ORIEN\03\24\v04
Policy & Procedure Manual
Section: Orientation/Training for                         Subject Title: <Virology Tube Culture>
        Technologists/Technician Manual                                  Bench Training Checklist
Issued by: LABORATORY MANAGER                             Original Date:
Approved by: Laboratory Director                          Revision Date:
                                                          Review Date: May 31, 2011

                               Virology Tube Culture BENCH

                  Area/Competency                      Employee     Date      Trainer     Date
                                                       Signature             Signature
24.1 The trainee has reviewed safety aspects
     including:
     a. The features of a Biosafety
     Containment 2 Lab.
     b. Virus Material Safety Data Sheet
     (MSDS).
     c. Operation of a 2-person Biosafety
     Cabinet.
     d. Use of centrifuge (e.g. cytospin) Safety
     Cups.
     d. Proper attire (gloves and front closed
     gown).
     e. Use of disinfectants, recycling cytoclips
     and waste disposal.
     f. Maintenance of liquid nitrogen tanks;
     storage and retrieval of viral isolates and
     cell cultures.
23.2 The trainee has reviewed
     duties/responsibilities including:
     a. Maintaining assigned inventories (ie.
     ordering fluorescent stains, culture media,
     supplements, liquid nitrogen etc.).
     b. Aliquot supplements (gentamicin,
     fungizone, vancomycin, FBS and
     glutamine), freezing media etc. for freezer
     storage.
     c.Maintaining cell lines (receiving, filing
     records, registering, seeding, refeeding
     and incubating as required for MRC-5,
     CMK, HFF and RD).
     c. Performing EBV assay.
     d. Maintaining liquid nitrogen tanks and
     their contents.
     e. Freezing isolates.
                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 47
                                                         Policy #             Page 2 of 3
                     Microbiology Department             MI\ORIEN\03\24\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                Area/Competency                    Employee    Date    Trainer     Date
                                                    Signature          Signature
24.3 The trainee has reviewed and familiar
     with performing tube cultures assay
     including:
     a. Reading, refeeding of tubes
     b. Recognizing each cell line having
     characteristics of toxicity, age, CPE,
     bacterial/fungal and foamy virus (CMK
     only) contaminations.
     c. Preparing cytospin preparations for
     fluorescent staining.
     d. Staining and reading of fluorescence
     stains.
24.4 The trainee has reviewed and is familiar
     with performing weekly QC for tube
     cultures including:
     a. Labeling, reading, recording and
     reporting uninoculated (C; V; N1, N2,
     N3).
     b. Reading, recording and reporting of
     HFF growth control (HSV1).
     c. Maintaining assigned (HSV1&2, CMV,
     RSV, Para3) QC isolates.
     d.
24.5 The trainee has reviewed and is familiar
     with the use of LIS for tube cultures
     including:
     a. Patient samples.
     b. QC samples.
     c. Receiving media (maintainence,
     supplements, cell lines, cell freeze) and
     reagents as well as changing reagent lots
     (inactivating old lot and activating new
     lot).
     d. Freezer storage (Soft Store).
     e. Removing pending items in tube culture
     worklist.




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       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                          Page 48
                                                         Policy #             Page 3 of 3
                     Microbiology Department             MI\ORIEN\03\24\v04
Policy & Procedure Manual
Orientation For Technologists Manual

#                Area/Competency                     Employee    Date    Trainer    Date
                                                     Signature          Signature
24.6 The trainee has reviewed limitations,
     sources of errors and remedies including:
     a. Foamy virus (replant to new lot).
     b. Toxic specimens (refeed/pass).
     c. Bacterial/fungal contaminations
     (report/replant).
     d. Aged cell lines/ lacking refeed
     (refeed/pass).
     e. Review of Virus - Cell Line Table.
24.7 The trainee has reviewed and is familiar
     with reporting including:
     a. Recording "F7 isolates" for LIS
     tracking positives.
     b. Informing ward and/or Infection
     Control for first reports of selected
     isolates.




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                           Page 49
                                                         Policy #                  Page 1 of 2
                      Microbiology Department            MI\ORIEN\03\25\v04
Policy & Procedure Manual
Section: Orientation/Training for                        Subject Title: <Roche Light Cycler
        Technologists/Technician Manual                                 PCR > Bench Training
                                                                        Checklist
Issued by: LABORATORY MANAGER                            Original Date:
Approved by: Laboratory Director                         Revision Date:
                                                         Review Date: May 31, 2011

                             Roche Light Cycler PCR BENCH

                 Area/Competency                     Employee     Date     Trainer     Date
                                                     Signature            Signature
25.1 Trainee is familiar with the general lab
     safety in the virology lab including the
     following:
     Material Safety Data Sheet (MSDS) of
     viruses; biosafety cabinet; gowns and
     gloves; disinfection and waste disposal.
25.2 Trainee has reviewed the procedure
     manual and is familiar with the principles
     and procedures of:
     a. West Nile virus RT-PCR RNA
     isolation, amplification and detection.
     b. Roche Light Cycler (LC) real time
     PCR.
25.3 Trainee is aware of the general
     precautions related to PCR procedures
     including:
     a. The physical separation of specimens,
     calibration and control materials, master
     mix and amplicons into 3 areas (sample
     prep; clean room and detection room).
     b. The proper use of gloves, gowns,
     filtered pipette tips and the danger of
     ribonuclase contamination. c. The specific
     storage and working temperatures for
     reagents and the need to mix and and
     centrifuge components.
     d. The maximum number of freeze-thaw
     cycles for samples and reagents.
     e. The need to work quickly in the cooling
     block.



                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                           Page 50
                                                          Policy #                   Page 2 of 2
                      Microbiology Department             MI\ORIEN\03\25\v04
Policy & Procedure Manual
Section: Orientation/Training for                         Subject Title: <Roche Light Cycler PCR
        Technologists/Technician Manual                                  > Bench Training
                                                                         Checklist

#                 Area/Competency                      Employee    Date      Trainer     Date
                                                       Signature            Signature
25.4 Trainee is aware of the Quality Control
     (QC) Procedures, their implications and
     their interpretations:
     a. Internal QC (non template control
     included in reagent kit)
     b. External QC (independent from reagent
     supplier and of known value: Accurun)
     c. Positive Control (Quantification
     Standard)
     d. Negative Control (H2O)
25.5 Trainee is aware of the need to perform
     Calibrations:
     a. Colour Compensation (on new
     instrument and every 6 months).
     b. Quantification standards
25.6 Trainee is familiar with the Artus PCR kit
     coupled with the operation of Light Cycler
     (LC) including:
     a. Use and interpretation of different
     fluorimeter channels
     b. Access and use trouble-shooting
     information
25.7 Trainee is familiar with the programming
     of the Light Cycler.

25.8 Trainee has incorporated internal,
     external, positive and negative QCs and
     has successfully demonstrated
     proficiencies in:
     a. Sample preparation and nucleic acid
     isolation using the Qiagen Spin Column.
     b. Amplification using Artus WNV RT
     PCR and related LC equipments.
     c. Detection and extraction of results using
     the LC software and hardware including
     the printing of graphs, interpretation and
     reporting of WNV PCR.

                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 51
                                                           Policy #                    Page 1 of 3
                       Microbiology Department             MI\ORIEN\03\26\v04
Policy & Procedure Manual
Section: Orientation/Training for                          Subject Title: Mycology Bench
        Technologists/Technician Manual                                   Training Checklist
Issued by: LABORATORY MANAGER                              Original Date: January 26, 2004
Approved by: Laboratory Director                           Revision Date:
                                                           Review Date: May 31, 2011

                                   MYCOLOGY BENCH

Training Period: Minimum four weeks
Mycology Team: Four to six Technologists

Teaching and Supervising Technologist: Subhash K. Mohan

Purpose: To demonstrate in direct smear, to isolate and identify yeast, the pathogenic, normal
commensal or saprophytic fungi capable of causing mycotic infections as well as to isolate and
identify Actinomycetes.

Safety: Knowledge of using Laminar Air Flow Safety Cabinet Type 2 and antimicrobial/
antifungal agents to be used on surfaces in the mycology laboratory.

#                 Area/Competency                      Employee     Date      Trainer      Date
                                                       Signature             Signature
26.1 The employee has reviewed the mycology
     section of the manual with the trainer.
26.2 The employees has demonstrated that they
     can accession new specimens in
     SOFTMic.
26.3 The employee has demonstrated that they
     can enter culture comments and result
     mycology specimens in SOFTMic.
26.4 The employee is aware of what are
     considered to be critical results.
26.5 Employee is aware of the correct
     procedures for handling specimens and
     fungus cultures. Including the use of
     safety cabinets and proper disinfection of
     the bench surfaces, incubators and
     refrigerators.
26.6 The employee is aware of the media used
                  to
     culture each type of specimen.
26.7 The employee is aware of the purpose of
     each culture medium used.

                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 52
                                                            Policy #                    Page 2 of 3
                      Microbiology Department               MI\ORIEN\03\26\v04
Policy & Procedure Manual
Section: Orientation/Training for                           Subject Title: Mycology Bench
        Technologists/Technician Manual                                    Training Checklist

#                  Area/Competency                      Employee     Date      Trainer      Date
                                                        Signature             Signature
26.8    The employee has demonstrated that
        they are proficient in the preparation and
        staining of fungal smears
26.9    The employee has demonstrated that
        they can set up a microscope using
        Kohler illumination.
26.10   The employee has demonstrated
        proficiency in reading and interpreting
        fungal smears using known control
        material.
26.11   The employee has demonstrated the
        proper technique in preparing:
        a. wet preparations of moulds using
        scotch tape
        b. tease mount
        c. slide cultures
        d. KOH prep
        e. Fungi-Fluor
        f. Calcofluor White

26.12   The employee is familiar with the
        procedures for
        setting up, reading and interpreting the
        following: a. germ tube,
        b. oxgall agar
        c. cornmeal agar
        d. EBM
        e. API 20C Aux
        f. RapID Yeast Plus
26.13   The employee has demonstrated that
        they can identify control organisms
        using procedures outlined in the manual.
26.14   Employee is aware of the proper
        protocol for referring specimens and
        isolates to the Public Health Laboratory
        (PHL) and histology.



                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                              Page 53
                                                           Policy #                    Page 3 of 3
                      Microbiology Department              MI\ORIEN\03\26\v04
Policy & Procedure Manual
Section: Orientation/Training for                          Subject Title: Mycology Bench
        Technologists/Technician Manual                                   Training Checklist

#                 Area/Competency                      Employee     Date      Trainer      Date
                                                       Signature             Signature
26.15   The employee is familiar with the
        reason for special staining by histology:
             a. GMS
             b. PAS
             c. H&E
             d. Mucicarmine
             e. Fontana Masson
             f. Giemsa.
26.16   The employee is familiar with the
        procedures for maintaining teaching,
        stock and control organisms.
26.17   The employee understand the growth
        requirements and handling procedures
        for:
        a. Histoplasma capsulatum and H.
        duboisii
        b. Blastomyces dermatitidis
        c. Coccidioides immitis and
        Paracoccidioides
        d. Sporothrix schenckii
        e. Penicillium marneffei
        f.Cryptococcus neoformans
26.18   The employee understands the following
        terms:
        a. Blastoconidia,
        b. Arthroconidia (contiguous &
        alternate)
        c. Macro and Micro conidia, Zygospore,
        d. Basidiospore
        e Tinea, Ring Worm, Dermatophyte
        f. Sporotrichosis,
        g. Mucormycosis (Zygomycosis)
        h. Pityriasis
        i. Actinomycosis
        j. Prototheca




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                             Page 54
                                                           Policy #                   Page 1 of 1
                      Microbiology Department              MI\ORIEN\03\27\v04
Policy & Procedure Manual
Section: Orientation/Training for                          Subject Title: Quality Control Bench
        Technologists/Technician Manual                                   Training Checklist
Issued by: LABORATORY MANAGER                              Original Date: January 26, 2004
Approved by: Laboratory Director                           Revision Date:
                                                           Review Date: May 31, 2011

                                     Quality Control Bench.

#                   Area/Competency                      Employee     Date      Trainer      Date
                                                         Signature             Signature
27.1    Familiar with functions in SoftMicqc: lot
        registration, inactivate and active lot, enter
        QC results.
27.2    Register all items to be QC’d into
        SoftMicqc
27.3    Perform required equipment, reagent,
        media QCs and enter results into
        SoftMicqc.
27.4    Register and perform QC on items not in
        SoftMicqc.
27.5    Vitek QC:
         registration new lot in Vitek
         prepare weekly loadlist
         Set up Vitek QC panels
         Review Vitek QC results
         enter QC action in SoftMicqc
27.6    Perform required Kirby Bauer and e-test
        QCs and enter results into SoftMicqc.
27.7    Check reagent cart to ensure reagent in use
        are the active lot in SoftMicqc and are not
        expired.
27.8    Perform Kirby Bauer disks inventory
        monthly.
27.9    Subculture working QC organisms weekly

27.10   Subculture stock QC organisms from the
        freezer monthly.
27.11   Subculture lyophilized stock QC
        organisms for the freezer annually.
27.12   Daily Environmental and Bone Bank
        Sterility Culture reading, workup and
        reporting.

                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                               Page 55
                                                         Policy #                   Page 1 of 1
                        Microbiology Department          MI\ORIEN\03\28\v04
Policy & Procedure Manual
Section: Orientation for Technologists Manual            Subject Title: Quality Management
                                                                       System Training
Issued by: LABORATORY MANAGER                            Original Date: July 3, 2002
Approved by: Laboratory Director                         Revision Date:
                                                         Review Date: May 31, 2011


                    QUALITY MANAGEMENT SYSTEM TRAINING


28. Quality Management System Training

                Area/Competency                    Employee    Date      Director     Date
                                                   Signature            Signature
28.1 Employee understands the structure of
     the Departmental Quality System
     (quality issues reporting structure,
     committees and responsibilities)
28.2 Employee is familiar with the
     departmental quality manual.
28.3 Employee is familiar with the quality
     essentials as applied to the department
28.4 Employee is familiar with the
     departmental occurrence management
     structure.
28.5 Employee is familiar with the quality
     improvement process




                                    PROCEDURE MANUAL
        UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                               Page 56
                             Record of Edited Revisions

Manual Section Name: Orientation for Technologists and Technicians

              Page Number / Item                      Date of Revision      Signature of
                                                                             Approval
Mycology Bench Checklist added                       January 26, 2004      Dr. T. Mazzulli
Quality Control Bench Checklist added                January 26, 2004      Dr. T. Mazzulli
Removed Parasitology Bench Checklist                 July 26, 2006         Dr. T. Mazzulli
Updated Planting and Accessioning manual             March 6, 2008         Dr. T. Mazzulli
Annual Review                                        May 31, 2011          Dr. T. Mazzulli




                                   PROCEDURE MANUAL
       UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT

                                           Page 57

								
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