"Nursing/Unlicensed Assistive Personnel Performance Evaluation Form - National Association of School Nurses"

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Box 40.6
SAMPLE NURSING/UNLICENSED ASSISTIVE PERSONNEL PERFORMANCE
EVALUATION TOOL
Job Description/Performance Standards
Name: __________________________ Evaluator: _________________________________
For the Period: ___________________________________________
Job Title: School Health Assistant
Fundamental Assignment: Assists school nurse with specific student health activities
Supervised by: ________________________________________________
Reports to: ____________________________________________________
Performance Level Criteria
Exceeds Performance Requirements
Work that is characterized by exemplary accomplishments throughout the rating period; performance
that is considerably and consistently above the requirements of the position to which the employee is
assigned. This level should be reserved for those employees who consistently excel in their job
performance.
Meets Performance Requirements
Work that meets the expectations and requirements of the assigned position throughout the rating period;
performance may fluctuate during the rating period to include exceeding the job requirements in some ar-
eas. This level will normally be used for all employees performing well and fully meeting expectations.
Below Performance Requirements
Substandard work performance below the job requirements.
Employee’s response, if desired:
The following attachments are a part of this report:
This is to certify that we have read and discussed the above report:
____________________________________________
___________________________________________
Employee’s Signature
Date
Supervisor’s Signature
Date
Performance Standards
1.0 Assists Registered Nurse
a. with health screenings.
b. to maintain and update student health records.
c. with administration of medication to students.
d. in providing delegated healthcare tasks for students with chronic health problems.
Job Activity 1-1: Assist RN with health screenings.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 1-2: Assist RN to maintain and update student health records.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 1-3: Assist RN with administration of medication to students.
Review Process: Direct observation and School RN input
(continued)
Copyright © 2013 National Association of School Nurses
1
Box 40.6
SAMPLE NURSING/UNLICENSED ASSISTIVE PERSONNEL PERFORMANCE
EVALUATION TOOL
Job Description/Performance Standards
Name: __________________________ Evaluator: _________________________________
For the Period: ___________________________________________
Job Title: School Health Assistant
Fundamental Assignment: Assists school nurse with specific student health activities
Supervised by: ________________________________________________
Reports to: ____________________________________________________
Performance Level Criteria
Exceeds Performance Requirements
Work that is characterized by exemplary accomplishments throughout the rating period; performance
that is considerably and consistently above the requirements of the position to which the employee is
assigned. This level should be reserved for those employees who consistently excel in their job
performance.
Meets Performance Requirements
Work that meets the expectations and requirements of the assigned position throughout the rating period;
performance may fluctuate during the rating period to include exceeding the job requirements in some ar-
eas. This level will normally be used for all employees performing well and fully meeting expectations.
Below Performance Requirements
Substandard work performance below the job requirements.
Employee’s response, if desired:
The following attachments are a part of this report:
This is to certify that we have read and discussed the above report:
____________________________________________
___________________________________________
Employee’s Signature
Date
Supervisor’s Signature
Date
Performance Standards
1.0 Assists Registered Nurse
a. with health screenings.
b. to maintain and update student health records.
c. with administration of medication to students.
d. in providing delegated healthcare tasks for students with chronic health problems.
Job Activity 1-1: Assist RN with health screenings.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 1-2: Assist RN to maintain and update student health records.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 1-3: Assist RN with administration of medication to students.
Review Process: Direct observation and School RN input
(continued)
Copyright © 2013 National Association of School Nurses
1
Box 40.6
(Continued)
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 1-4: Assist RN in providing delegated healthcare tasks to students with chronic health problems.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job activity 1-5: Follows written and verbal directions.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
2.0 Provides authorized first aid to students.
Job Activity 2-1: Provision of first aid.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 2-2: Documents student encounters.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 2-3: Communicates effectively and appropriately with students, parents, nurse, and school
personnel regarding care given.
Review Process: Direct observation, School Principal and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
3.0 Collects immunization data.
Job Activity 3-1: As above.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
4.0 Contributes to a positive and productive work environment.
Job Activity 4-1: Communicates effectively and appropriately with nurse and others in work environment.
Review Process: Direct observation, School Principal and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Job Activity 4-2: Manages multiple tasks.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Copyright © 2013 National Association of School Nurses
2
Box 40.6
(Continued)
Other Job Functions
1.0 Attends department and other staff meetings.
Job Activity 1-1: As above.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
2.0 Performs other related duties as assigned.
Job Activity 2-1: As above.
Review Process: Direct observation and School RN input
EVALUATION:
Exceeds Performance
Meets Performance
Below Performance
Does Not Apply
Comments:
Source: Shared by permission of Multnomah Education Service District, Department of School Health Services, Portland, Oregon.
Copyright © 2013 National Association of School Nurses
3
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