CEBU INSTITUTE OF TECHNOLOGY – UNIVERSITY

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PERFORMANCE EVALUATION CHECKLIST FOR COMMUNITY HEALTH

NURSING EXPOSURE

Name: Level: Evaluation Date:

1 - Very Poor 2 - Poor 3 - Good 4- Very Good

Check in appropriate column:

1 2 3 4
Behavior/Skill VP P G VG
1. Care of the family

1.1 Establishes rapport with the family

a. Identifies the following:

1.2.1 Reaction to the illness of family member

1.2.2. Effects of illness on the family
1.2.3 Coping strategies
1.3 Analyzes strengths and weakness of the family
1.4 Identifies the family nursing problems
1.5 Works with the family in planning the care and and/or
rehabilitation of the sick member
1.6 Implements care plan with family
1.7 Evaluates plan of care
1.8 Documents care given
2. Health teaching among population group

2.1 Identifies health information needs of population groups

2.2 Develops plan for health teaching of population groups based
on identified needs and characteristics of target audience/clientele
2.3 Prepares appropriate and relevant teaching materials
2.4 Implements plan for health teaching

2.4.1 Uses language understandable by the audience

2.4.2 Actively involves the audience in the teaching / learning
process
2.4.3 Uses visual aids correctly
2.4.4 Speaks loud enough to be heard by everybody in the
audience
2.5 Evaluates results of health teaching
3. Demonstrates attributes of future professional

3.1 Shows awareness of own feelings and reactions and their

effect on family.
3.2 Accepts suggestions and constructive criticisms.
3.3 Manifests self-direction
3.3.1 Reports for duty/ conference/ consultation on time
3.3.2 Submits requirements on time
3.4 Utilizes teacher’s supervision effectively
 1 2 3 4
Behavior/Skill VP P G VG

3.4.1 Discusses difficulties encountered

3.4.2 Seeks closer supervision when needed
3.5 Shows active participation in group conference/ward classes
4. Demonstrate core values

4.1. Show honesty in data gathering, problem identification,

implementing intervention, reporting, and evaluating
outcomes
4.2 Manifests consistency in beliefs and actions
4.3 Show sensitivity to social problems affecting the health status of
the clientele being served.
4.4 Consider the ethnic orientation of the family/client.
4.5 Displays critical thinking in the analysis of the health problems of
the client/family
4.6 Shows commitment to prove the health situation of the
Community
4.7 Discerns bioethical implications when making decisions
4.8 Shows compassion and commitment to the welfare of the client
and family
4.9 Demonstrate competence and confidence to in performing
nursing actions
4.10 Demonstrate gender sensitivity in patient care.

4.11 Ensure safety, comfort, and privacy in rendering care.

4.12 Consider a holistic perspective of the client.

4.13 Demonstrate situational flexibility and adaptability
4.14 Displays competence in the use of the nursing process in
different settings
4.15 Models good health habits

TOTAL SCORE:

Student’s Signature & Date C.I.’s Signature & Date