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INITIAL PERFORMANCE VALIDATION: END OF ASSESSORS’ INITIALS & SIGNATURES
Validation Methods:
SELF ASSESSMENT
ORIENTATION
SKILLS / TASKS and/or VALIDATION O = Observed performance SELF ASSESSMENT _________ _____________________________
PROCEDURES and/or D = Skills Lab demo/ VALIDATION _________ _____________________________
performance

EQUIPMENT Date: _______________ L = Learning assessment
form/Test Date: ________ _________ _____________________________
C = Chart review

V = Verbalized _________ _____________________________
Check 1 column below: PR = Policy Review Check 1 column:
N/A = Not applicable or no
opportunity at the facility

Date Met &
Assessor Initials:
Can Need Never Validation Task completed or Can Do Need COMMENTS:
Do Review done Methods: Procedure Review Needs Review?
Performed
Correctly
**
interagency etc.) adhering to transfer
guidelines, policies and requirements
[ex sending to surgery, sending to
another facility], based on EMTALA
guidelines
EDUCATION:
Provides and documents appropriate
patient and family teaching.
Verifies teaching effectiveness using
appropriate methods (ex. teach back,
return demo, questions).
Demonstrates use of policies,
procedures, and other resources [ex.
self- learning, continuing education] in
the ongoing changing care of patients
and families.
LEADERSHIP:
Communicates honestly, effectively,
and ethically with all people in the
health care area using the methods
[ex. AIDET] defined by the
organization.
Demonstrates effective work as a
team member; and/or team leader.
Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 7