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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
**
and management of Central Venous
Access Devices (medication
administration, blood draws, dressing
changes, and drawing type and cross).
Fall Prevention:
Uses the Morse fall risk assessment as
a tool for identifying patients at risk
for fall.
Verbalizes process, and
documentation required should a
patient fall.
Immunization:
Verbalizes process for the appropriate
administration and documentation of
vaccines.
IV Starts and Maintenance: 1. 1. 1.

Demonstrates 3 successful IV starts.
2. 2. 2.

3. 3. 3.
Demonstrates appropriate IV
maintenance.
Post Mortem Care:
Appropriately complete post mortem

Revised 081517 ** Levels: Novice/Beginner (B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E) *AGE SPECIFIC & POPULATION SPECIFIC COMPETENCIES 15