NURS: Certified School Nurse Program - Competency Feedback Form

Millersville University
Certified School Nurse Program

Competency Feedback Form

STUDENT INFORMATION

P ID#

Student Last Name

Student First Name

Academic Year

Beginning Date of Evaluation Period

End Date of Evaluation Period

Level

Program

Certification Area

Select Evaluation Timeframe

Mid-Evaluation (7.5 weeks)

Final Evaluation (15 weeks)

EVALUATOR INFORMATION

Certified School Nurse (CSN) Preceptor First Name

Certified School Nurse (CSN) Preceptor Last Name

Placement School

Placement District

MU Faculty Liaison/Supervisor

Instructions:
Based on the CSN Program Competency Feedback Form completed at the end of NURS610 and NURS611, please rate the certified school nurse candidate by selecting the rating that corresponds with the sections identified on the Competency Feedback Form.

Overall Evaluation

Rating	Unsatisfactory (0) 75% or fewer completed	Emergent (1) 76-89% completed	Expected (2) *90-94% completed*	Exemplary (3) 95-100% completed
Criteria for Rating	The Candidate’s performance does not meet expectations for a certified school nurse..	The Candidate’s performance shows the potential of developing into the role of a proficient novice school nurse.	The Candidate’s performance aligns with the standard expectations of an effective novice school nurse..	The Candidate’s performance mirrors that of an accomplished novice school nurse.
To satisfactorily complete this evaluation and qualify for recommendation for Pennsylvania Educational Specialist PK-12 School Nurse certification, a minimum total of at least five (5) points must be attained on the final overall evaluation with an “Emergent” (1) rating or higher in each of the five (5) sections.

Section 1: Participation in suggested learning experiences.

Unsatisfactory (0)

Emergent (1)

Expected (2)

Exemplary (3)

Comment:

Section 2: PDE Educator Effectiveness Observation and Practice – Framework for Non-Teaching Professionals: School Health Specialist (June 2021)

Unsatisfactory (0)

Emergent (1)

Expected (2)

Exemplary (3)

Comment:

Section 3: Pennsylvania Department of Education Standards for School Nursing (2017)

Unsatisfactory (0)

Emergent (1)

Expected (2)

Exemplary (3)

Comment:

Section 4: Accommodations and Adaptations for Diverse Learners – Guidelines to Inform the Work of the School Nurse (2009)

Unsatisfactory (0)

Emergent (1)

Expected (2)

Exemplary (3)

Comment:

Section 5: Meeting the Instructional Needs of English Language Learners (2009)

Unsatisfactory (0)

Emergent (1)

Expected (2)

Exemplary (3)

Comment:

Final Rating:

Justification:

Provide pertinent points to justify the overall rating. Consider areas of specific strengths and/or areas for growth in relation to the five sections on the Competency Feedback Form.
(Optional: List evidence to support the justification.)

Journals

Interactions with Preceptor

Other

Recommended Action:

I, the Candidate’s Evaluator, having compiled and retained evidence of justification, make the recommendations noted below.

To be completed at the end of NURS610 or before:

Continued participation in the School Nurse Certification Program

Removal from the School Nurse Certification Program

To be completed at the end of NURS611:

Approval of the Candidate’s recommendation for PDE certification

Denial of the Candidate’s recommendation for PDE certification at this Final Evaluation

Date of Evaluation Completion:

Name of MU Faculty Completing this form:

Required Signatures:

Evaluator Signature:

Click to Sign...

Evaluator Email

I hereby affirm that the information in this document is correct and true to the best of my knowledge.

Check the box if this form is ready to be sent to the candidate and their email has been entered below.

School Nurse Candidate Email

By signing, the Candidate acknowledges receipt and review of this evaluation (not necessarily agreement).

School Nurse Candidate Name:

School Nurse Candidate:

Click to Sign...

A copy of this completed/signed document must be provided to the Candidate. Another copy must be submitted to and retained by the Institution of Higher Education according to the record retention policy guidelines. 4

NURS: Certified School Nurse Program - Competency Feedback Form

Millersville University Certified School Nurse Program

Competency Feedback Form

Millersville University
Certified School Nurse Program