Travel Nurse Reference/Evaluation form

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_____________