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Facility:  PAH  PFH  PHH PMH PNH PNtH

Emergency Department Nurse / Paramedic
Initial Skills Validation Checklist
Employee Name:

Employee Number:

Department and/or Unit:

Years of Experience in general Nurse work _______Years

Years of Experience with the unit type patient’s _______Years

New Graduate Nurse _____
Agency/Contract/Temp Nurse _____

Qualified Competency Assessors:
Manager, Educator, Preceptor, POCT Coordinator, Clinical Nurse Specialist

I understand that it is my responsibility to have completed and to return the New Orientation Competency Assessment packet to my
supervisor/manager/educator prior to my end of orientation evaluation. This paperwork will then be placed in my file in my department
along with my orientation performance evaluation.

Date Nurse Signature
Agree to Statement above

Orientation Completed

Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 1