Title Page
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Site conducted
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Employee Name
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EID #
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Location
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Observed by
Validation occurs when the employee can perform the skill safely, correctly an legally with minimal coaching. Any skill or competency that does not apply to the specific service area, can be marked with "N/A"
Hand Hygiene/Glove Removal
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Date
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Describes appropriate hand hygiene technique and opportunities
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Engages in social motivation tactic to ensure proper hand hygiene
Patient Relations/Service Approach
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Date & Time
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Demonstrates a friendly/service approach
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Uses ISIT correctly
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Waits for permission to enter room
Hard Floor Care
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Date
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Prepares and uses chemicals according to policy
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Uses different color/size pads appropriately
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Demonstrates correct and consistent processes of cleaning & maintaining equipment
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Demonstrates correct and consistent processes of scrubbing and re-coating a floor
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Demonstrates correct and consistent processes of stripping a floor
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Demonstrates correct and consistent processes of applying floor finish
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Demonstrates correct and consistent processes of burnishing floors
Cleaning Practices
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Date
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Prepares and uses chemicals according to policy
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Demonstrates correct and consistent process of cleaning an occupied room
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Demonstrates correct and consistent process of cleaning a restroom
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Demonstrates correct and consistent process of cleaning a discharge room
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Demonstrates correct and consistent process of cleaning an extra area
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Stocks linen according to job description for the designated areas
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Staging rooms for patient readiness
Waste and Dirty Linen Processing
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Date
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Demonstrates the proper use of PPE work with waste and dirty linen
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Demonstrates the disposal of sharps container according to policy
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Demonstrates the disposal of Chemo waste container according to policy
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Demonstrates the disposal of black medical waste container according to policy
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Demonstrates the disposal of solid waste according to policy
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Demonstrates the disposal of Bio-Hazard waste
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Demonstrates the proper process of dirty linen
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Demonstrates the proper process for aluminum, newspaper, magazine, and plastic recycling
Fire Safety
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Date
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Can verbalize RACE & PASS
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Identifies the location of the fire pulls & verbalizes how to use the pull
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Identifies the location of the fire exits and fire extinguishers
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Prevent the blocking of any safety equipment: doors, fire pull or extinguishers
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Identifies the use of 9-911
Pager and Computer Use
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Date
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Access One Chart and performs task in program accurately (start & end shift, complete rooms and leave notes)
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Can access and enter information into the Work Order System
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Responds to the pager in an appropriate and timely way
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Demonstrate successfully the practice of using the pager to "page" someone
I verify this employee has met the ongoing competencies identified for their position
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General Comments
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Manager/Reviewer E-Signature
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Date Signed
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Employee E-Signature
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Date Signed
