UNIVERSITY OF BELIZE

DEPARTMENT OF NURSING

Clinical Evaluation Form (Ongoing)

DATE: UNIT:
STUDENT NAME:
The performance evaluation is divided into the following sections:
I. Personnel Policies: Attendance and Punctuality
II. Clinical Management: Administration/Supervision of Clinical Area
III. Clinical Skills: Prenatal. Child Health, Post natal, Disease Surveillance, Health education etc.
IV. Recording and Reporting

Rating Scale

Appraising Rating Definition

Excellent Significantly exceed criteria at all times. Consistently demonstrates
 A(95-100) outstanding performance and competency in the use of skills and in
 A- (90-94) application of knowledge in patient care delivery and public health
nursing practice, showing high level of initiative, consistently sound
judgment and excellent decision making.
Exceeds Professional Consistently meets and exceeds criteria and demonstrates superior
 B+(85-89) proficiency in skills and application of increasing knowledge in
 B (80-84) patient care delivery and public health nursing.
Professional Standards Performance that demonstrates the ability to meet the criteria in
 C+ (75-79) patient care delivery and safe nursing practice and exceeds
 C (70-74) requirements in one or more major aspects of work.
Marginal Performance Performance that inconsistently demonstrates basic skills and
 D+(65-69) knowledge for safe patient care delivery and public health nursing
 D (60-64) practice.
Failure Unsatisfactory performance which does not meet normal
requirements of position.
Measures used to evaluate the quality of public health nursing practice and all other related work
performance of the student will include the following but not limited to:
 Direct Observations
 Demonstration of Skills
 Individual Conferences: Pre/post conferences (report)
 Communication (clinical management, leadership, supervision etc)
 Assessment, planning, implementing and evaluation of services/program in clinical areas.
 Anecdotal Records (recording)
Guidelines: This evaluation form will be used for the ongoing evaluation of the student. Place the letter
grade and the corresponding number grade in the appraisal section of the evaluation form. An average
will be computed and a final grade will be given to the student. Passing mark is C+. There is a space for
the evaluator to make comments.

Partially adopted from UTECH­Jamaica (Evaluation Form for BsN Public Health Nursing)  Page 1 
RESPONSIBILITIES APPRAISAL COMMENTS
1. PERSONAL POLICIES
Punctuality: Report on and off duty is
prompt.
Provides proper notification for
absences and tardiness.
Utilizes time well.
Attire/Appearance: Clean and proper
poise.
Observes the institution dress code.
Wears identification badge at all
times.
Professionalism: Demonstrates
initiative flexibility, responsibility
and accountability.
Demonstrate competence in
professional nursing roles.
Incorporates Standards of
Professional Nursing Practice and
Nursing Code of Ethics into its own
scope of practice.
Establishes professional relationships
with individuals, groups and
communities for the purpose of
collaboration and partnership.
Is willing to commit self to patient
and family needs.
Is persistent in trying to upgrade
nursing care.
Utilizes resources selectively
Recognizes own limitations.
Seeks assistance appropriately
Considered competent & trustworthy.
Conforms to policies governing
patient abuse, patient rights and
confidentiality of information.
Ethics: Addresses ethical issues from
an informed personal and professional
value system.
Integrates the professional values of
altruism, autonomy, commitment,
dignity, social justice, stewardship
and veracity into the nursing role.
Critical Thinking: Synthesizes
nursing plans of care addressing
holistic needs of individuals, families

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and communities that include health
promotion, risk reduction, disease
prevention and/or illness
management.
Engages in critical thinking processes
resulting in competent nursing
practice.
Communication: Uses therapeutic
and professional communication
skills.
Integrates therapeutic communication
into relationships with individuals,
groups and community.
Practices professional communication
in the nursing role.
Incorporates informational and health
care technologies into the practice of
professional training
Expresses self clearly and accurately.
Personal Development: Accepts
constructive criticism regarding
nursing actions/judgment.
Responds to instruction from
supervisors.
Relates previous learning to new
situations.
Is able to grasp new information and
directions readily.
Assumes responsibility for continuing
education and developmental needs.
Seeks assistance appropriately from
supervisor and other health team
members relating
clinical/management problems.
Total
2. CLINICAL MANAGEMENT
Assess the health needs of clients
based on review of clinical records.
Selects necessary equipment for
clinic.
Ensure that equipments is
functioning.
Delegates duties according to the
level and preparation and expertise of
staff members.

Partially adopted from UTECH­Jamaica (Evaluation Form for BsN Public Health Nursing)  Page 3 
Makes the physical setting
comfortable for clients and staff.
Supervises other members of staff in
carrying out their tasks.
Carries out nursing procedures with
due consideration for client’s safety,
comfort and privacy.
Assist in determining necessary
resources to provide for patient needs.
Check cards at the end of the clinic
and summarizes data to evaluate the
effectiveness of clinical services.
Conducts pre and post conferences on
a daily basis.
Total
3. CLINICAL SKILLS
Prenatal: Utilizes the nursing process
to assess, plan, implement and
evaluate nursing care.
Able to describe the components of
prenatal care.
Conduct biopsychosocial assessment
of the childbearing client.
Knowledgeable of the management of
maternal high risk conditions.
Identify high risk conditions in
pregnancy.
Knowledgeable of the management of
maternal high risk conditions.
Conduct health education session to
meet the needs of the childbearing
population.
Keeps daily records of all official
activities done during the day.
Prevention of Vertical Transmission
of HIV: Demonstrate knowledge on
the management of the HIV pregnant
mothers and infants born from HIV
mothers.
Ability to conduct pre and post HIV
test counseling.
Demonstrate knowledge of criteria for
taking blood samples from infants
born from HIV mothers.
Child Health: Utilizes the nursing
process to assess, plan, implement

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and evaluate nursing care.
Knowledgeable of the child’s growth
and development.
Identify benefits of breastfeeding.
Demonstrate skills in maintaining the
cold chain: during preparation,
administering, storing and
transporting vaccines.
Demonstrate knowledge of vaccines:
their side effects and schedule.
Demonstrates competency in vaccine
administration.
Integrated Management of
Childhood Illnesses: Knowledgeable
of the common conditions affecting
children less than 5 years.
Knowledgeable of children
micronutrients available and their
mode of administration.
Knowledgeable of the preparation and
administration of oral rehydration
salt.
Post Natal: Knowledgeable of the
changes in the post natal period.
Knowledgeable of the assessment and
examination of the new born.
Knowledgeable of the assessment and
examination of the post natal woman.
Able to identify physical and
emotional changes during post natal
period.
Demonstrate knowledge of infant
nutrition specifically related to
nutrition.
Cancer Screening: Ability to conduct
papsmear testing.
Ability to conduct breast
examination.
Ability to identify common sexually
transmitted infections as primary
cause of cervical cancer.
Family Planning: Knowledgeable of
family planning methods.
Able to refer clients to family
planning agencies.
Conduct family planning educational

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sessions for adolescent and adult.
Surveillance: Identify illnesses under
the surveillance system.
Ability to describe the investigation
process for immuno-preventable
diseases.
Knowledgeable of active and passive
surveillance systems available.
Knowledgeable of surveillance
reporting system.
Health Education: Assist clients
through teaching to identify,
understand and meet their health
needs.
Identify different methods for health
education within the different
facilities, school or community
settings.
Access health information to identify
health needs of the population.
Conduct educational session to
individuals, groups and population
according to their health needs
Mobile/Outreach Services: Identify
outreach services available for the
population.
Utilizes these services appropriately
and effectively to make health
services accessible and affordable to
the community.
Home Visiting: Establishes priority
home visits based on assessment of
needs identified.
Review health records and formulates
objectives to meet the identified
needs.
Select appropriate equipment needed
for the specific home visit.
Selects appropriate literature to be
taken on home visits.
Prepares community nursing bag.
Demonstrates skills in carrying out
the different phases of home visit.
Applies principles of interviewing
and counseling in carrying out visits.
Demonstrates skills in applying the

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bag technique.
Carries out home visiting based on
the family centered approach.
Discuss literature with clients.
Plans frequency of follow-up visits
based on family needs and/or
institution policies.
Demonstrate skill in discarding soiled
disposable articles from home visits.
Referral System: Assist clients in
utilizing available community
resources to meet their needs.
Collaborate with other members of
the health team in providing health
care for clients.
Knowledgeable of sources for
referring pregnant high risk clients,
children with potential or high risk
problems and victims of domestic
violence.
Total
4. RECORDING AND
REPORTING
Keeps daily records of all official
activities.
Writes reports accurately, concisely,
legibly.
Assists in compiling monthly reports.
Uses established clinic procedure for
recording.
Records pertinent and vital
information on approved forms.
Demonstrates skills in filling records
in keeping with system of assigned
clinic.
Keeps Clinical Tutor currently
informed on significant aspects of
family under her care.
Total

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 5. ADMINISTRATION AND
SUPERVISION
Supervises and delegates
responsibility to nursing personnel for
direct/indirect nursing care of patient.
Coordinates the development,
implementation and evaluation of
nursing services.
Takes appropriate steps to solve
problems and address staff needs.
Schedules, assigns, guides, direct and
instructs nursing personnel in nursing
activities.
Shows initiative in making decisions
relating to any aspect of her work.
Plans work in keeping with the
policies and philosophy of local
health department.
Identifies training needs of other
categories of health care workers and
meet these needs.
Assist in planning training program to
meets identified needs through
conference, workshop.
Total

SUPERVISOR’S SECTION
NAME: DATE:

Evaluation Checklist
a. Was the entire clinical period considered? Yes: _____ No: _____
b. Was every task/clinical skills considered? Yes: _____ No: _____

Summary of Rating-Check one only.

The total sum and average of each item is considered to arrive to one grade. After completion of
the evaluation the following are the grades for each component:
Personal :________ Clinical Management: _______

Clinical Skills: _________ Recording and Reporting: _________

Administration and Supervision: _______

Partially adopted from UTECH­Jamaica (Evaluation Form for BsN Public Health Nursing)  Page 8 
Identify areas of strengths within the students:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Areas of Improvement:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Plans for Improvement (suggestions for developing the student):

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

General Comments
Overall impression of the student’s work in your facility:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How would your organization use this clinical experience in the future?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Supervisor/Evaluator’s Signature: ______________________ Date: __________________

I was aware of the evaluation process and it was discussed with me.
Yes: ______ No: ______

Student’s Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Student’s Signature: _________________________ Date: ________________________

Thank you for serving as a preceptor for this intern and for completing the
evaluation of the intern. Your ratings will be useful in preparing this
student for future work and in improving the clinical experience for other
students.

Partially adopted from UTECH­Jamaica (Evaluation Form for BsN Public Health Nursing)  Page 9