Clinic Campus Checklist

COMPREHENSIVE SCHOOL HEALTH DEPARTMENT
School Nurse Evaluation
Nurse: Title: Campus:
Date: Campus Enrollment: Nurse Absences: Punctuality:
Certifications: CPR CPR Instructor Hearing Vision Spinal AN
Continuing Education:
Campus Committees:
ATTIRE:
Appropriate/Professional:
Name Tag:
STUDENT HEALTH RECORDS:
Notebooks in place: YES NO
Manila Folder (if necessary): YES NO
IHP: YES NO
504: YES NO
Child Find: YES NO
Special Educ. YES
NO
PPCD/ Self contained/
Life Skills: YES NO
Medications: YES
NO
Referrals: YES NO
SCHOOL HEALTH PROGRAM REQUIRED REPORTS:
Immunization – Vision – Hearing – Spinal – AN Diabetes Risk Assessment Type II
Timeliness:
Accuracy:

CLINIC RECORDS:
Clinic Visits:
Monthly Reports:
Entered in Timely Manner: Yes NO
Medications: Daily OTC Errors
PRS:
GEH:
Monthly Biological:
Accident / Incident:
911 Calls: Fractures: Special Procedures:
Pulse Oximeter:
AED Check:
Emergency Bag:
CLINIC ORGANIZATION:
Atmosphere:
Cleanliness:
Clinic Bulletin Board:
Age appropriate decorations:
HEALTH TEACHING:
Students: Outline covered, materials used, etc.:
Staff: Bloodborne Pathogens CPR
Employee Wellness Activities (Health Fairs, Blood Screenings, etc.):
Blood Screening (No. of Participants):
Other Comments:
NURSES’S SIGNATURE
DATE
SUPERVISOR’S SIGNATURE
DATE
01/30/2009
Revised 03/02/2010 JE