NAME: Location Performance Review Date:

SCALE 1 = OUTSTANDING 2 = HIGHLY EFFECTIVE 3 = EFFECTIVE 4 = IMPROVEMENT NEEDED 5 = UNACCEPTABLE

RESPONSIBILITIES	Rating	COMMENTS
Quality of Work
1. Practices according to the philosophy, standard and policies as established by the Department of Nursing Service.
2. Seeks Guidance as needed from the RN
3. Communicates information concerning client status to the Registered Professional Nurse.
4. Practices appropriate Infection Control techniques
5. Demonstrates organizational skills when completing assignments.
Professional Conduct
1. Contributes to the maintenance of adequate unit staffing by accepting reassignment and rotating tours of duty.
2. Respects different cultures and religious beliefs of others.
3. Communicates in a courteous, sensitive manner.
4. Performs tasks and duties other than assigned according to the needs of the department.
5. Demonstrates an ability to work consistently with co-workers.
6. Uses appropriate channels of communication with client and/or significant other, nursing staff and other health team members.
7. Demonstrates flexibility in differing works situations.
8. Functions well as a member of the health care team.
9. Conducts and appears in a professional manner at all times.
10. Arrives at work regularly on time.
11. Attends all mandatory inservice programs.
12. Maintains credentials and educational files as per JCAHO standards and Contract standards.

Evaluator: Title: Date:

Employee: Title: Date:

Please write Goals, Accomplishments and Comments on the reverse side.