<p>CONTINUING COMPETENCY REVIEW OF NON-CHS NURSING PROFESSIONALS</p><p>Name: Date Submitted:</p><p>Exact name as shown on license:</p><p>Status: RN PNP FNP NNP LPN</p><p>Alabama Board of Nursing License: Expiration Date:</p><p>Verification of license by supervising MD or designee:</p><p>Signature: </p><p>Current Employer: UAB CRS Outside Agency Other</p><p>Department: Phone:</p><p>Current Position:</p><p>Supervised by:</p><p>Nurse’s home address: </p><p>Nurse’s e-mail address:</p><p>DATES OF ANNUAL INSERVICES/REQUIREMENTS (Must be completed EVERY 12 MONTHS or nurse will NOT be allowed to practice at CHS)</p><p>I have read the Information Handbook for Non-CHS Nurses (If not applicable complete 1,2,3, below)</p><p>Date Completed: Signature:</p><p>DATE COMPLETED DATE COMPLETED THIS YEAR LAST YEAR</p><p>1) Children’s Hospital Fire Safety:</p><p>2) Patient Safety:</p><p>3) Children’s Hospital Infection Control:</p><p>4) CPR: (required every 24 months)</p><p>(Xeroxed card required)</p><p>5) PPD Skin Test</p><p>(verification of positive or negative results required)</p><p>CONTINUED ON NEXT PAGE</p><p>6) Age-Specific Competency checklist completed and attached. Must have signature of evaluator on checklist. Four pages attached.</p><p>7) Has your Job Description changed? Yes No If yes attach new Job Description.</p><p>8) Performance Improvement (state what improvements you have made in your Nursing Practice this past year):</p><p>9) Ongoing Competency Education (list Contact hours and inservices attended over the past year or attach separate list):</p><p>As of January 2007, Nursing Administration requires a written annual evaluation on Nurses as part of the Evaluation Form on the next page. If your Supervisor completes an annual evaluation on you already the evaluation can be attached to fulfill the requirement.</p><p>Even if this is your first year in the position an evaluation has to be written. Criteria to complete a brief evaluation includes: experience, certifications, specialized training, observations in the clinical area, feed back from coworkers and students if you are a Nursing Instructor. These are just offered as helpful ideas to complete the evaluation process.</p><p>So when you give the Evaluation Form to your supervisor point out the new requirement because it will not be complete without an evaluation.</p><p>Yearly Evaluation Form</p><p> meets all requirements of the designated position/role and has been deemed competent to perform all job duties as related to their role at CHS.</p><p>Evaluation:</p><p>Annual evaluation indicates the following performance: (please check)</p><p>_____ Exceptional</p><p>_____ Satisfactory</p><p>_____ Unsatisfactory (please explain)</p><p>Date completed: ______</p><p>Evaluator’s signature: ______</p><p>Written: June 1992 Revised: Aug 1993, Aug 1995, Aug 1996, Aug 1997, Jan 2000, Jul 2004, Mar 2007</p>