Evaluation Worksheet for Certificate Phlebotomy
SID: ________________________________ Skills Certificate - 5043
  Effective: Fall 2014
  Health Sciences
Name: ________________________________ (707) 527-4272

REQUIREMENTS: Complete 7.5 units

Phlebotomy Requirements - complete 7.5 units
CourseDescriptionUnitsCompletedIn ProgressComments
HLC 111 Phlebotomy7.5   

Program Requirements Notes:

Health and Safety: Due to blood and body fluid exposure during skills lab, all students will be required to have the following immunizations before entry into program: MMR (measles, mumps, rubella), Varicella zoster (Chicken pox), Tetanus (Tdap), PPD ( 2 injections a week apart), Hep B (2 of 3 series must be completed 3 weeks before skills lab), and Influenza (Flu vaccine). Students must clear a physical examination during the health screening process. Students will be required to complete background clearance. The name of background screening agency and program code will be given at orientation.

    Evaluation worksheet completed upon receipt of Transfer Credit Evaluation form. Includes credit from other institutions only received to date.

    Evaluation worksheet completed for ________________________________. Includes all SRJC and transfer credit received to date.

Units completed:    __________
Units in progress:    __________
Total:    __________
    Requirements Completed
    Pending (work in progress)
    Requirements Not Completed



Date: ________________________   By: ____________________________________________