Aprn/Rn/Lpn Nursing Supervisor's Report Form - Nevada

This "Aprn/Rn/Lpn Nursing Supervisor's Report Form" is a document issued by the Nevada State Board of Nursing specifically for Nevada residents with its latest version released on October 6, 2015.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Nevada State Board of Nursing.

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N
Nevada State Board of
URSING
APRN/RN/LPN Nursing Supervisor’s Report
Name of Nurse:
Date:
(Please print or type)
(Due last day of month)
Employer: __________________________________________ Department/unit: _____________________
To meet reporting requirements with the Nevada State Board of Nursing because my license is being monitored, please
complete the following. (Attach additional pages as needed)
1.
Attendance – please itemize any absenteeism, reasons for the absences, and provide the average number of
hours worked by the nurse per pay period.
2.
Job Performance:
a.
Consistently carries out assigned nursing functions.
Yes
No
b.
Consistently handles work stress/stressors appropriately.
Yes
No
c.
Complies with all rules, policies and procedures.
Yes
No
d.
Displays consistent behavior pattern without upsets or changes.
Yes
No
Please use the space below to explain any “No” answers or for any additional comments:
3.
Has the nurse been warned/counseled for any reason? (Please explain if yes or attach counseling form)
Has the nurse had access to controlled substances?
Yes
No
No Restriction
4.
Has the nurse been placed in a position where he/she is ‘In Charge’?
(‘Charge Nurse’ means a first line manager who has basic skills in supervision and leadership and has the authority
to so function.)
Yes
No
No Restriction
5.
Please attach any additional information you feel would assist the Board in its review of the nurse’s
practice.
Name of Supervisor:
Title:
(Please print or type)
Signature
Telephone number
Date
E-mail completed forms to:
compliance@nevadanursingboard.org
or;
Fax completed forms to: 775-687-7729 (Please do not fax multiple copies) or;
Mail to: NSBN, Compliance Coordinator, 5011 Meadowood Mall Way, Ste 300, Reno, NV 89502-6576
Revised 10/06/15
N
Nevada State Board of
URSING
APRN/RN/LPN Nursing Supervisor’s Report
Name of Nurse:
Date:
(Please print or type)
(Due last day of month)
Employer: __________________________________________ Department/unit: _____________________
To meet reporting requirements with the Nevada State Board of Nursing because my license is being monitored, please
complete the following. (Attach additional pages as needed)
1.
Attendance – please itemize any absenteeism, reasons for the absences, and provide the average number of
hours worked by the nurse per pay period.
2.
Job Performance:
a.
Consistently carries out assigned nursing functions.
Yes
No
b.
Consistently handles work stress/stressors appropriately.
Yes
No
c.
Complies with all rules, policies and procedures.
Yes
No
d.
Displays consistent behavior pattern without upsets or changes.
Yes
No
Please use the space below to explain any “No” answers or for any additional comments:
3.
Has the nurse been warned/counseled for any reason? (Please explain if yes or attach counseling form)
Has the nurse had access to controlled substances?
Yes
No
No Restriction
4.
Has the nurse been placed in a position where he/she is ‘In Charge’?
(‘Charge Nurse’ means a first line manager who has basic skills in supervision and leadership and has the authority
to so function.)
Yes
No
No Restriction
5.
Please attach any additional information you feel would assist the Board in its review of the nurse’s
practice.
Name of Supervisor:
Title:
(Please print or type)
Signature
Telephone number
Date
E-mail completed forms to:
compliance@nevadanursingboard.org
or;
Fax completed forms to: 775-687-7729 (Please do not fax multiple copies) or;
Mail to: NSBN, Compliance Coordinator, 5011 Meadowood Mall Way, Ste 300, Reno, NV 89502-6576
Revised 10/06/15

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