Sample) Competency.
*use to assess clinical competecy

Step 1.

Step 2.

Step 3.

Step 4.

Step 5.

Step 6.

Step 7.

Step 8.

Step 9.

Step 10.

Step 11.

Step 12.

Step 13.

Step 14.

Step 15.

Step 16.

Step 17.

Step 18.

1. During the assessment, the assessor assigns a category corresponding to the performance level for each of the performance criteria (see below key)
2. If the performance falls into the category "NYC", comments must be included, comments are optional if category "C" is demonstrated/achieved
3. A digital copy of the completed assessment tool is provided for the clinician as well as filed in the health care worker's personnel file. (to provide a copy email result to the staff member's email address and copy to HR, if the staff member does not have email send a written request to HR to provide a printed copy).

C (Competent)
Performance level: Standard of practice is at or above the performed criteria outlined
Action required: Aspects of performance that are satisfactory are documented and positive feedback given to the clinician.

NYC (Not Yet Competent)
Performance Level: Standard of practice is below the performance criteria outlined
Action Required: All areas in which the standard of performance is below the criteria are discussed and documented through the use of examples of actual and expected practice. The clinician is provided with a learning program and times may be arranged for further practice so that the expected standard can be achieved within a prescribe timeframe.

Assessment Outcome

Performance Level Acheived


Employee Name


Assessor Name
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.