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 family: ________________
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