______School District #___
Support Staff Evaluation
Nurse
Employee______Number of Years in Position______
Building/s______Number of Years in District______
Evaluator______School Year______
Attendance:
Reports to Work on Time AlwaysUsuallySeldomNever
Sick Day Use Light AverageHeavyExcessive
Special Circumstance: ______
Performance Responsibilities:
Performance ratings reflect a composite based primarily on the indicators that appear under each performance responsibility. The evaluator will mark non-applicable indicators with “NA.”
Performance Rating Scale:4=Demonstrates model performance
3=Meets district expectations
2=Needs some improvement
1=Needs immediate attention
Circle One
- Attends to temporarily ill, chronically ill and injured students and staff4 3 2 1
as evidenced by:
____Provides temporary first aid care in the absence of nurse or physician
____Offers comfort and care to students until parents arrive
____Monitors students and staff condition in order to provide information to
medical professionals, if requested
____Conducts blood monitor tests and other minor tests per parent’s request
and training
____Accompanies injured party to hospital as requested
____Other______
- Supervises the students’ self administration of medication per District policy 4 3 2 1
as evidenced by:
____Monitors the student to ensure that appropriate dosage is ingested
____Stores medications in appropriately secured cabinets and areas
____Monitors changes in type/dosage of medication
____Maintains accurate medication log for all medications taken on site
____Maintains ongoing communication with parents regardingmedications
and related procedures
____Other______
- Supports and contributes to a healthy, safe and sanitary educational 4 3 2 1
environment as evidenced by:
____Maintains clean and sanitary conditions in the health office
____Conducts checks and follow up activities related to lice infestation
____Uses universal precautions
____Informs building administrator about injuries related to safety
hazards
____Requests assistance of building custodian/s when cleanup is indicated
____Conducts cleanup in the absence of custodian
____Requisitions, maintains inventory and distributes health and first
aid supplies
____Other______
- Contributes to the organization and maintenance of up-to-date student4 3 2 1
health files and related records as evidenced by:
____Works in cooperation with other health personnel to create
health files for new students
____Reviews health files to ensure sufficient knowledge of students’
health conditions
____Participates in computer data entry of student medical information
____Other______
- Ensures ongoing communication regarding students’ health conditions 4 3 2 1
among parents, students, medical professionals, teachers, administrators
and other health personnel as evidenced by:
____Prepares and distributes detailed student information form for
serious health conditions to staff
____Provides appropriate notification regarding contagious illnesses
and conditions
____Contacts parents of students who are ill or injured
____Notifies teachers of restrictions on students’ activities
____Offers information regarding free health services as requested
____Contacts medical professionals regarding health matters of students
____Provides to parents records of readings or other health monitoring data
____Other______
- Completes reports accurately and in a timely manner as evidenced by:4 3 2 1
____Prepares and submits accident reports for student and staff injuries
____Completes forms required by the county health departments
____Maintains daily log of visitors to the health office detailing time,
reason for visit and treatment administered
____Completes Mecca-Tech record on schedule
____Other______
- Provides general assistance in the school office, as needed as 4 3 2 1
evidenced by:
____Assists with maintenance of student records and other files
____Greets and processes parents and other visitors
____Answers telephone and directs calls appropriately
____Other______
- Maintains a positive attitude towards job related growth and 4 3 2 1
development as evidenced by:
____Attends appropriate inservice training and workshops
____Learns about conditions of students when new or unusual
cases are presented
____Adapts positively to change
____Demonstrates initiative
____Other______
- Develops and maintains positive relations with students, staff and4 3 2 1
community as evidenced by:
____Maintains confidentiality of all student and staff records
____Provides general information regarding illnesses and diseases
____Exhibits a calm and comforting demeanor when speaking
with parents and staff
____Treats and communicates with others with dignity and respect
____Demonstrates flexibility and a cooperative attitude in daily interactions
____Engages in positive problem-solving with peers and supervisors
____Other______
- Performs manual tasks that support the educational program and4 3 2 1
operation of the school as evidenced by:
____Provides physical support to students as needed
____Assists in restraining a child in an emergency
____Moves equipment and materials as required
____Other______
Evaluator’s Comments:
Areas of Strength:
Areas for Growth:
Evaluator’s Signature______Date______
Employee’s Acknowledgement:
This evaluation has been reviewed with me in person. I understand what has been presented to me and I have had an opportunity to respond to all items.
Employee’s Response (Optional):
Employee’s Signature:______Date______