Name of Nurse:_________________________________________________________
Hospital Name and Address:_______________________________________________
_________________________________________________________
Name of Evaluator:_____________________________ Position:___________________
Telephone Number for future Contact:________________________________
Dates of Contract (from:)_________________ (To:)_____________________
Please rate the travel nurse with the following scale:
Exceeds standards: 3 Meets standards: 2 Below Acceptable Standard: 1
Quality: Work Habits:
Delivers care in a timely and safe manner:___________ Utilization of time: ____________
Charting is accurate thorough and concise:__________ Follows Work Instructions: ______
Reports changes in condition appropriately:___________ Efficiant use of equipment: ______
Professionalism_______ Tardiness:_____ Sicktime:_______
Emotional Stability _____________
Personal Relations:
Willingness to be flexible:____________
Offers assistance to co-workers:__________
Requests assistance as needed:_________
Creates rapport with Patients and family:___________
Acceptance of Supervision:_________
Competency:
IV Skills:_____________
Assessment Skills:____________
Performs within scope of practice:_______
Knowledge of Conditions specific to unit:_________
Medication/IVPB Knowledge:___________
Complies with Hospital Procedures and policies:_________
Computer Documentation if Used:__________
Would you recommend this nurse for rehire or future contracts (Yes/No): _________
How many beds are there on your unit: ________ in the Hospital: ____________
ER trauma Level___
Would you be willing to provide a reference for this nurse (Yes/No)_________________
Any recommendations for improvements or other comments:_____________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Signature of Evaluator________________________________________ Date_____________
Form Courtesy of NurseTraveler.org