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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
**
Demonstrates effective airway
assessment and management (trach
care, suctioning, positioning,
pulse oximetry, secretion
management).

Rhythm/ECG management:
Recognizes and manages rhythm and
ECG changes appropriately.

Safe Patient Handling Equipment:
Demonstrates correct use of lift
equipment (only demonstrate
equipment used in your area)

 Maxi –Move Lift
 SARA Plus Lift
 SARA 3000 Lift
 SARA Stedy Lift
 TENOR Lift
 MAXI SKY Lift
 MAXI AIR
 MAXI Slides

Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 13