ࡱ> PROg 'bjbj 6r\r\lllll4$?>??????$xA.D%?l%?ll:?SSSll>S>SS#/>U:>">P?0?9>DDD>Dl>$S%?%?S?D> 2: PERALTA COMMUNITY COLLEGE DISTRICT COLLEGE NURSE FACULTY OBSERVATION FORM (For Non-Health Discipline Observers) COLLEGE NURSE:______________________________________________ College____________________________ Semester______________ Acad. Yr.___________________ Name of Faculty Observer______________________________________ Date___________________ Appropriate input regarding the Evaluee is encouraged through the appropriate representatives on the Committee. Individuals wishing to participate in the evaluation process should have direct knowledge of the College Nurse=s skills (e.g. have worked with or observed the College Nurse in committee work, department meetings, student contact, public contact, etc.). Please comment on the following, as appropriate for your period of observation of the College Nurse during an individual session with a student or staff member: a. The College Nurse made the student/staff member feel comfortable and was attentive to his/her concerns. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ b. The College Nurse was helpful in providing information and support. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ The College Nurse based health screenings, tests, treatments or advice on the student/staff presenting problem and subsequent problems that arose during the session. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ The College Nurse gave the student/staff the opportunity to ask questions. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ The College Nurse gave referrals to community resources that were appropriate for the financial, ethnic, cultural and personal needs of the student/staff. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ In your opinion, what in the session observed appeared to be most helpful to the student? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ In what way(s), if any, could the College Nurse have been more helpful or effective in the session with the student/staff? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please comment on any of the additional areas below that you were able to observe or have knowledge of regarding the College Nurse: a. Demonstrates responsibility and accountability for day-to-day operation of the Health Services Center. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ b. Participates in shared governance system; chairs/serves on college/district committees. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Works cooperatively with faculty, administrators, staff and students. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Provides appropriate health education programs. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Handles conflict/stress situations appropriately. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Is accessible to students. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Keeps current in the discipline (including specialized information necessary to perform the duties of the position). ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Effectively advocates for student/staff health needs on campus. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Maintains appropriate record-keeping systems. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Maintains confidentiality regarding student/staff health information. __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ Demonstrates sensitivity to diversity of staff and students (including ethnicity, gender, disability, religion, age, sexual orientation). __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ Communicates effectively (both oral and written). __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ OVERALL PERFORMANCE RATING: ____SuperiorBsurpasses requirements; exceeds expectations _____SatisfactoryBmeets all standards of excellence as described in the policy ____Below StandardsBdoes not consistently meet requirements ____UnsatisfactoryBdoes not meet requirements; ineffective Observer: Date: ___________________ Evaluee: ________________________________________________ Date: _____________________ The evaluees signature on this form does not constitute acceptance of this evaluation. 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