NURSING PERFORMANCE EVALUATION

The nurse who is requesting that you complete this form has been placed under terms by Order of the
Virginia Board of Nursing. This Order is a public document and may be obtained from the nurse or from
the Boards webpage or its offices. The Order requires the nurse to ensure that a quarterly performance
evaluation is submitted by the nurses supervisor until the nurse is released in writing from the Order.
Please complete and return this form with your original signature by the last day of the current quarter. Please complete and return this form with your original signature by the last day of the current quarter.
Reports must be received within 5 days before or after this date to be acceptable. Faxes are not Reports must be received within 5 days before or after this date to be acceptable. Faxes are not
accepted. accepted.
Nurses Name: _______________________________________ License No.
_____________________
This report covers ! "an#Mar ! A$r#"un ! "u%#Se$ ! Oc&#'ec ()_______
'a&e o* Em$%o+men& ___________________ 'a&e Termina&e,-Resi.ne,
____________________
Name an, Posi&ion o* Imme,ia&e Su$er/isor: ______________________________________________
0. UNIT - T1PE OF NURSING CARE (chec all that apply!
( ! "edical #urgical ( ! O$%$ecovery ( ! #taffing &gency ( ! '()
( ! *$ ( ! &dministrative ( ! +sychiatry ( ! +ediatrics
( ! (hemical ,ependency ( ! -ome -ealth ( ! OB%./N ( ! Nursing -ome
( ! Other 0 11111111111111111111111111111111111111111111111111111111111111111111111111
(. POSITION (chec all that apply!
( ! #upervisor ( ! #taff ( ! 'nstructor
( ! (harge nurse ( ! +rivate ,uty ( ! Other 1111111111111111111111111111
2. S3IFT-3OURS 4OR5 (chec all that apply!
( ! days ( ! nights ( ! evenings ( ! full time ( ! part time 2 list hours wored each month3 111111
( ! +$N 0 list dates and hours wored during report quarter3 111111111111111111111111111111111
6. ATTEN'ANCE (respond to each question!
11111 Number of days absent in the past 4 months. +attern of absence e5ists6 ( ! No ( ! /es E7$%ain3
11111 Number of days tardy in the past 4 months. +attern of tardiness e5ists6 ( ! No ( ! /es E7$%ain3
8. 9UALIT1 OF 4OR5 (respond to each question!
( ! *5cellent ( ! #atisfactory ( ! Needs 'mprovement ( ! )nsatisfactory 0 E7$%ain3
,ate of employers last +erformance *valuation3 111111111111111
-as an evaluation or counseling session been held with the nurse in the past 4 months6 ( ! No
( ! /es ( ! 7ritten3 Pro/i,e Co$+ : E7$%ain ( ! Verbal3 E7$%ain3
-ave there been any incident reports8 complaints8 or concerns reported about this nurse6 ( ! No
( ! /es3 Pro/i,e co$+ : E7$%ain3
;. ME'ICATION 'UTIES (respond to each question!
,oes this nurse administer medications6 ( ! /es ( ! No.
'f yes8 are there any restrictions6 7hat types of drugs are administered6 11111111111111111111111111
'f no8 does the nurse have access to medications6 ( ! /es ( ! No.
-ow often are medication records reviewed for accuracy6 11111111111 ( ! $egularly ( ! Occasionally
,o you believe the employee is maintaining abstinence from all mood0altering chemicals8 including alcohol
and prescription medications6 ( ! /es ( ! No
<. INTERPERSONAL RELATIONS3IPS
7ith patients3 ( ! Very .ood ( ! #atisfactory ( ! Needs 'mprovement 0 E7$%ain3
7ith the public3 ( ! Very .ood ( ! #atisfactory ( ! Needs 'mprovement 0 E7$%ain3
7ith co0worers3 ( ! Very .ood ( ! #atisfactory ( ! Needs 'mprovement 0 E7$%ain3
=. NOTIFICATION OF OR'ER
7ere you informed of the (onsent Order%Order by the nurse6 ( ! No ( ! /es 7hen611111111111
7ere you provided with a com$%e&e copy of the (onsent Order%Order by the nurse6 ( ! No ( ! /es
'f required by the Order8 were you notified of Board approval for this employment6 ( ! No ( ! /es
'f required by the Order8 were you notified of Board approval for this employment6 ( ! No ( ! /es
If you answered no to any question in #8, please contact the Nursing Compliance Case Manager at
the Board of Nursing at 804!"#4$%$& 'here may (e restrictions on the nurse)s practice&
Your cooperation is appreciated. If you have any questions concerns or comments please feel free to
contact the !ursing "ompliance "ase #anager at the $oard at %&'()*+('5,5 or to list them below.
Si.na&ure
'a&e
Ti&%e o* E/a%ua&or
A.enc+ or Faci%i&+
A,,ress
Ci&+-S&a&e->i$
Te%e$?one
Num@er
$ev. 4%9%:;;<
SEN' REPORTS TO: The Board Of Nursing8 c%o =Nursing (ompliance (ase "anager>
<<?; "ayland ,r.8 #uite 4;;8 -enrico8 Virginia :4:440@9?4. (all A;904?B09C@C with questions.
EAPLANATIONS - 9UESTIONS - CONCERNS - COMMENTS: