Evaluation/Reference Form






The following has been compiled by the very helpful group at Delphi Travel Nurse and Therapist Forum. The forum has been a wealth of information to me. This form is only one small offering that might make your travel career a bit easier.


Use it as is, or change it to make one that suits you. Hand it out to your Unit Supervisor, Charge Nurse, Nurse Manager, or co-worker and keep for your own files.








Evaluation/Reference Form

Personnel Performance Evaluation Date:
Hospital: and Unit:
Name and Position and Shift:

Please use the scales below to rate the nurse above with the following appropriate level of scoring.

Exceeds Standards :---------- 3
Meets Standards :------------ 2
Below Standards:------------- 1


QUALITY
Delivers care in a timely, safe manner:
Charting is accurate, thorough and concise:
Reports significant changes in a timely manner:

WORK HABITS
Utilization of time:
Followed work instructions:
Efficient use of equipment and supplies:
Complies with dress code:

PERSONAL RELATIONS
Willingness to be flexible:
Offers assistance:
Requests assistance if needed:
Rapport with patients and public:
Acceptance of supervision:

COMPETENCY
IV skill:
Assessment skills:
Performs within Scope of Practice:
Knowledge of conditions specific to unit:
Medication/IVPB Administration:
Complies with facilities policy /procedures:
Computer documentation:

Would you recommend this nurse for rehire/ future contracts? _____________

Comments (please use back of form if you need more room)
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_______________________________________________________signature and title










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