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:
Hour
00
10
20
30
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50
Minutes
What class is the student in?
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A
B
C
Evening
A Shift
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Please Select
Brown
Crown
Downs
Friedman
Fuentes
Gonzales
Gosnell
Lombardi
Mccolgan
Patterson
Robinson
Stidham
B Shift
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Chimenian
Clark
Collins
Cooper
Fowler
Lally
Pauley
Pavelka
Staub
Stoddard
Sword
C Shift
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Please Select
Begosh
Decker
Eckroade
Keeney
Kough
Leonard
Peterson
Santucci
Shaffer
Swann
Wigmore
Evening Class
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Please Select
Ale
Dana
Decamp
Flanary
Gunawardana
Hunt
Kaffi
Knoyer
Lopez-Puentes
Manon
Mejias
Olson
Sahadzic
Sakaria
Who is the Evaluator?
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Instructor
A Shift Student Evaluator
B Shift Student Evaluator
C Shift Student Evaluator
Evening Class Student Evaluator
Instructor
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Please Select
Burkhammer, Michele
Cleveland, Susan
Cordero, Jennifer
Cousins, Robert
Dugan, Pete
Gorodetsky, Nelly
Hayunga, Joe
Herman, Geoffrey
Hutchinson, David
Kauffman, Mike
Kinna, Donald
Le Renard, Yann
Leigh, Michael
Lipp, Troy
Lofland, Larry
Luger, Brian
Newman, David
Ney, Kirk
Nosbisch, Nick
Oliveira, Rae
Ruff, Greg
Scott, Tony
Shawl, Jon
Singer, Arye
Stottlemyer, Ty
Strudwick, Rosni
Sweder-Gold, David
Touzeau, Chris
Turcotte, Jeremy
Weinstock, Sam
Wooden, Andrew
Zea, Alejandro
A Shift Student Evaluator
*
Please Select
Brown
Crown
Downs
Friedman
Fuentes
Gonzales
Gosnell
Lombardi
Mccolgan
Patterson
Robinson
Stidham
B Shift Student Evaluator
*
Please Select
Chimenian
Clark
Collins
Cooper
Fowler
Lally
Pauley
Pavelka
Staub
Stoddard
Sword
C Shift Student Evaluator
*
Please Select
Begosh
Decker
Eckroade
Keeney
Kough
Leonard
Peterson
Santucci
Shaffer
Swann
Wigmore
Evening Class Student Evaluator
*
Please Select
Ale
Dana
Decamp
Flanary
Gunawardana
Hunt
Kaffi
Knoyer
Lopez-Puentes
Manon
Mejias
Olson
Sahadzic
Sakaria
Selects, checks, assembles equipment
IV solution
Administration set
Catheter
Sharps container
Universal start kit(antiseptic swabs, gauze pads, venous tourniquet, occlusive bandage, antibiotic gel, syringe, etc.)
Performs venipuncture
Takes or verbalizes appropriate PPE precautions
Gathers and prepares equipment
Connects administration set to IV bag
Prepares fill chamber and flushes IV tubing
Locates vein
Cleanses site
Performs venipuncture and notes flash
Disposes of needle
Opens administration set, looks for infiltration, sets appropriate drip rate
Secures catheter and applies occlusive dressing over puncture site
Affective
Accepts evaluation and criticism professionally
Shows willingness to learn
Interacts with simulated patient and other personnel in professional manner
Critical Criteria
Failure to establish a patent EJ within 3 attempts
Contaminates equipment or site without appropriately correcting the situation
Failure to dispose/verbalize disposal of syringe and other material in proper container
Exhibits unacceptable affect with patient or other personnel
Uses or orders a dangerous or inappropriate intervention
Evaluator Comments
Was the student successful or unsuccessful in this skill?
*
Successful
Unsuccessful
Signature
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