Instructions: Please complete the information below. Be sure to select your group on the left below (CBC, RMCHP, or FP if OUTPATIENT, OR a Service if INPATIENT / HOSPITAL). In addition, select the corresponding clinic or hospital service (drop down menu). AGENCY: Please use last 6 digits of social security number. Employee Information Emp ID First Last UTMB Clinics --- SELECT SITE --- CSB 4 - Endoscopy --- UHC --- (select site) UHC 3 - Ob/Gyn UHC 4 - Cardiac Rehab UHC 4 - Chronic Home Dialysis UHC 4 - Echo UHC 4 - Galv Fam Med UHC 4 - Int. Med/Harborside Med Grp UHC 4 - Stark Diabetes UHC 5 - Dermatology UHC 5 - Medicine Specialties UHC 5 - Oral Surgery UHC 5 - PT/OT UHC 5 - Surgery Specialties UHC 7 - Pedi Specialties UHC 7 - Island Pediatrics UHC 7 - Galveston RMCHP ---OTHERS--- Aviation Medicine Emergency Room Stark Diabetes - UEC Student Wellness Telemedicine Electrophysiology Lab UTMB Radiology CBC ---SELECT SITE--- Cancer Center - Dickinson Clinic Clear Lake Pedi Specialty Derm & GI - Dickinson Island Pedi Urgent Care Ctr Mainland Med Spec - Texas City MedSurg Spec - Friendswood Neuro & Pain Mgmt - Friendswood Pedi Assoc - Alvin Pedi Assoc FHC - Friendswood Pedi Assoc FHC - League City Pedi Assoc - Texas City Pedi Urgent Care - South Shore Radiology Center - Friendswood Radiology Specialty Procedures Stewart Road FHC Texas City FHC Texas City Geriatrics Oceanview Women's Hlth & Univ Fertility Ctr Other RMCHP --- SELECT SITE --- *ADMINISTRATIVE* ANGLETON BEAUMONT BIRTH CENTER CONROE DICKINSON GALVESTON PCP HUNSTVILLE KATY LIVINGSTON MCALLEN NACGADOCHES NEW CANEY ORANGE PASADENA PEARLAND PRAIRE VIEW STAFFORD TEXAS CITY VICTORIA WHARTON other Hospital Service -----SELECT SITE----- Austin Women's Hospital **** Old John Sealy **** OR - PACU OR HOLDING ***JS Towers (select one)*** J2A/B/C L&D J2D - BICU J3A/B - Ante-Partum J3C - Newborn Nsy J3D - ISCU J4A - SICU J4B - MICU/CCU J4C/D - Cardiac Cath Lab J5A/B -GCRC J6C/D Ante/Post Partum J7D - Med/Surg J8A - Day Surgery J8B - Dialysis J8C/D - Ante/Post Partum J9D - Transplant J10A - Pedi J10C/D - ACE Unit ---TDCJ (Select One) --- TDC 6A - Day Surg TDC 6B - Surgery TDC 6C - Women's TDC 7A - Telemetry TDC 7B - Med ***MISC*** ER/ FAST TRACK ENDOSCOPY OTHER Date: Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Year 2009 2010 1. The urine specimen should be examined within ____hr(s) of collection, or it should be refrigerated (then warmed to room temp before running). one two four 2. After dipping, color changes that occur after the specified times on the bottle are of no diagnostic value and must not be considered or reported. TRUE FALSE 3. Just prior to testing, the specimen should be: stirred with the dip stick inverted ten or more times not mixed or inverted 4. Who is responsible for performing quality control and recording quality control results? Test Site Manager Point of Care Coordinator Person performing patient testing 5. MULTISTIX Urine dip sticks are good for one year after opening for three months after opening until the expiration date on the vial even if the vial has been opened b or c.- whichever comes first 6. 7. 8. 9. 10.
UTMB Clinics --- SELECT SITE --- CSB 4 - Endoscopy --- UHC --- (select site) UHC 3 - Ob/Gyn UHC 4 - Cardiac Rehab UHC 4 - Chronic Home Dialysis UHC 4 - Echo UHC 4 - Galv Fam Med UHC 4 - Int. Med/Harborside Med Grp UHC 4 - Stark Diabetes UHC 5 - Dermatology UHC 5 - Medicine Specialties UHC 5 - Oral Surgery UHC 5 - PT/OT UHC 5 - Surgery Specialties UHC 7 - Pedi Specialties UHC 7 - Island Pediatrics UHC 7 - Galveston RMCHP ---OTHERS--- Aviation Medicine Emergency Room Stark Diabetes - UEC Student Wellness Telemedicine Electrophysiology Lab UTMB Radiology CBC ---SELECT SITE--- Cancer Center - Dickinson Clinic Clear Lake Pedi Specialty Derm & GI - Dickinson Island Pedi Urgent Care Ctr Mainland Med Spec - Texas City MedSurg Spec - Friendswood Neuro & Pain Mgmt - Friendswood Pedi Assoc - Alvin Pedi Assoc FHC - Friendswood Pedi Assoc FHC - League City Pedi Assoc - Texas City Pedi Urgent Care - South Shore Radiology Center - Friendswood Radiology Specialty Procedures Stewart Road FHC Texas City FHC Texas City Geriatrics Oceanview Women's Hlth & Univ Fertility Ctr Other RMCHP --- SELECT SITE --- *ADMINISTRATIVE* ANGLETON BEAUMONT BIRTH CENTER CONROE DICKINSON GALVESTON PCP HUNSTVILLE KATY LIVINGSTON MCALLEN NACGADOCHES NEW CANEY ORANGE PASADENA PEARLAND PRAIRE VIEW STAFFORD TEXAS CITY VICTORIA WHARTON other Hospital Service -----SELECT SITE----- Austin Women's Hospital **** Old John Sealy **** OR - PACU OR HOLDING ***JS Towers (select one)*** J2A/B/C L&D J2D - BICU J3A/B - Ante-Partum J3C - Newborn Nsy J3D - ISCU J4A - SICU J4B - MICU/CCU J4C/D - Cardiac Cath Lab J5A/B -GCRC J6C/D Ante/Post Partum J7D - Med/Surg J8A - Day Surgery J8B - Dialysis J8C/D - Ante/Post Partum J9D - Transplant J10A - Pedi J10C/D - ACE Unit ---TDCJ (Select One) --- TDC 6A - Day Surg TDC 6B - Surgery TDC 6C - Women's TDC 7A - Telemetry TDC 7B - Med ***MISC*** ER/ FAST TRACK ENDOSCOPY OTHER
1. The urine specimen should be examined within ____hr(s) of collection, or it should be refrigerated (then warmed to room temp before running).
one two four
2. After dipping, color changes that occur after the specified times on the bottle are of no diagnostic value and must not be considered or reported.
TRUE FALSE
3. Just prior to testing, the specimen should be:
stirred with the dip stick inverted ten or more times not mixed or inverted
4. Who is responsible for performing quality control and recording quality control results?
Test Site Manager Point of Care Coordinator Person performing patient testing
5. MULTISTIX Urine dip sticks are good
for one year after opening for three months after opening until the expiration date on the vial even if the vial has been opened b or c.- whichever comes first
6.
7.
8.
9.
10.
