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Sample Employee Evaluation Form: School Nurse (RN Staff Nurse) Job Function 1: Provides quality health services

for students to help assure a school environment that supports a free appropriate public education for all children.
Above Expectations At Expectations Needs Improvement Unsatisfactory Performance

JF1.1: Documents the application of the nursing process in a responsible, accountable, and ethical manner. JF1.2: Participates in quality improvement activities. JF1.3: Participates in ongoing education activities related to appropriate knowledge bases and professional issues. JF1.4: Applies knowledge of current practice standards, guidelines, statutes, rules, and regulations. JF1.5: Uses Code of Ethics for Nurses with Interpretive Statements (ANA 2001) and Code of Ethics with Interpretive Statements for School Nurses (NASN 1999a) to guide practice. JF1.6: Utilizes the best available evidence, including research findings, to guide practice decisions. Comments:

Job Function 2: Promotes parent and community involvement to support positive health and educational outcomes for students.
Above Expectations At Expectations Needs Improvement Unsatisfactory Performance

JF2.1: Shares knowledge and skills with peers and colleagues JF2.2: Communicates with the student, the family, and healthcare providers regarding student care and the school nurses role in the delivery of that care. JF2.3: Collaborates in creating a documented Page 1 of 4

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healthcare plan that is focused on outcomes and decisions related to care and delivery of services and indicates communication with students, families, and others. JF2.4: Documents referrals, including provisions for continuity of care. JF2.5: Maintains student confidentiality within legal and regulatory parameters of both health and education. JF2.6: Assists the student and the family in identifying and securing appropriate and available services to address health-related needs. JF2.7: Engages in team work as a team player and a team builder. Comments:

Job Function 3: Maintains accurate records and reports according to school district policies and procedures to meet legal and funding requirements.
Above Expectations At Expectations Needs Improvement Unsatisfactory Performance

JF3.1: Adopts and uses available technology appropriate to the work setting. JF3.2: Implements health procedures according to school district policies and/or standards. JF3.3: Applies strategies to obtain appropriate resources for nursing initiatives. Comments:

Job Function 4: Promotes wellness in the school setting to minimize absences by students and school personnel.
Above Expectations At Expectations Needs Improvement Unsatisfactory Performance

JF4.1: Develops and implements health policies and procedures in collaboration with Page 2 of 4

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school administration. JF4.2: Develops and implements needed wellness initiatives using a program planning process. Comments:

Job Function 5: Under certain conditions, selects, trains, determines the competency of and evaluates the work of licensed practical nurses and/or school personnel who are not licensed nurse to help assure continuity of care for students.
Above Expectations At Expectations Needs Improvement Unsatisfactory Performance

JF5.1: Documents referrals, including provisions for continuity of care. JF5.2: Orients, trains, documents competency, and evaluates licensed practical nurses and/or school personnel who are not licensed nurses as appropriate to the school setting. Comments:

Job Function 6: Identifies and facilitates resolution of safety concerns in the school setting in order to promote a safe and healthy school environment.
Above Expectations At Expectations Needs Improvement Unsatisfactory Performance

JF6.1: Conducts school environmental needs assessments to identify safety concerns and identify ways to promote a safe and healthy school environment. JF6.2: Develops and implements needed safety programs using a program planning process. Comments:

Job Function 7: Other duties as assigned.


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Comments:

General Performance Factors:


Above Expectations At Expectations Needs Improvement Unsatisfactory Performance

1. Accepts Change 2. Accepts Direction 3. Accepts Responsibility 4. Attendance 5. Cooperation 6. Effectiveness Under Work Stress 7. Grooming and Attire 8. Initiative 9. Meeting Deadlines 10. Observance of Work Hours 11. Operation and Care of Equipment 12. Organization of Work Station 13. Works Independently Comments:

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