REEVALUATION OF UNLICENSED TEAM MEMBER PERFORMANCE Delegation Teaching TASK: ________________________________________________________________________________ PERSON RECEIVING SUPPORTS: ___________________________________________________________ UNLICENSED TEAM MEMBER: ____________________________________________________________ REGISTERED NURSE: ___________________________________________________________________ Approved TEAM REVIEW RN length up DEMONSTRATED COMPETENCY & COMMENTS MEMBER DATE INITIAL to 180 YES/NO INITIAL days My Initials in the corresponding boxes indicate that I have been observed performing the delegated task and agree with the corresponding statements and I am willing to continue do this task. _______ _____________________________________________________ Initial Team Member Signature My initials in the above corresponding boxes indicate I have assured the corresponding statements are true, and that I am continuing to delegate this task. _____ _____________________________________________________ RN Initial Registered Nurse’s Signature
REEVALUATION OF UNLICENSED TEAM MEMBER PERFORMANCE Delegation Teaching TASK: ________________________________________________________________________________ PERSON RECEIVING SUPPORTS: ___________________________________________________________ UNLICENSED TEAM MEMBER: ____________________________________________________________ REGISTERED NURSE: ___________________________________________________________________ REVIEW DATE RN INITIAL TEAM MEMBER INITIAL Approved length up to 180 days DEMONSTRATED COMPETENCY & COMMENTS YES/NO My Initials in the corresponding boxes indicate that I have been observed performing the delegated task and agree with the corresponding statements and I am willing to continue do this task. _______ _____________________________________________________ Initial Team Member Signature My initials in the above corresponding boxes indicate I have assured the corresponding statements are true, and that I am continuing to delegate this task. _____ _____________________________________________________ RN Initial Registered Nurse’s Signature
REEVALUATION-OF-UNLICENSED-TEAM-MEMBER-PERFORMANCE-11-2016.docx