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Revised 8.1.15
USD 385 School Nurse Pre-Observation Planning Form
School Nurse: ____ __________________________ Building:_____________________________
Date of Pre-conference:_________________ Date & Time of Observation:___________________ Activity to Observe: _______________________________________________________________ Briefly describe what you anticipate the administrator will see or hear during your planned observation as it relates to the rubric assigned to your area of specialty.
Revised 8.1.15
USD 385 School Nurse Observation-Interview Form
School Nurse:____________________________________________ Date:___________________
Observer: _______________________________________Building: ________________________
Activity Observed:__________________________________ Time In & Out:_________________
Domain 1: Planning and Preparation *Demonstrates medical knowledge & nursing skills *Demonstrates knowledge of child & adolescent development *Establishes appropriate program goals *Demonstrates knowledge of government, community, and district regulations & resources *Plans program for individuals & groups integrated with regular school program *Develops evaluation plan of school nursing program
Domain 2: The Environment *Establishes environment of respect and rapport *Establishes culture for health & wellness *Follows health protocols & procedures *Supervises health associates *Organizes physical space
Domain 3: The Delivery of Service *Assesses student needs *Administers medications to students *Manages emergency situations *Demonstrates flexibility & responsiveness *Collaborates with teachers to develop specialized programs and services for students with diverse medical needs
Domain 4: Professional Responsibilities *Reflects on practice * Maintains health records & submits in timely fashion *Communicates with families *Participates in professional community *Engages in professional development *Shows Professionalism
Revised 8.1.15
USD 385 School Nurse Reflection Form
School Nurse:_________________________________________ Building:__________________ Date of Post-conference:________________ Date of Observation/Interview:________________
Please comment on the different aspects of your delivery of services during the planned observation/interview. What aspects of your delivery of services were effective? Why?
What would you do differently to improve the delivery of services?
Revised 8.1.15
USD 385 School Nurse Feedback Form and Rubric
School Nurse ____________________________________________ Activity Observed _________________________
Observer______________________________ Observation Date_____________ Post-Conference Date_____________
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Directions:
With the school nurse, examine all the evidence generated in the service provided.
Look jointly at the Levels of Performance by component for each domain. Highlight or circle the relevant part(s) of
the statements. Together, review the Domain Summaries and develop suggestions for future practice.
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Revised 8.1.15
DOMAIN 1: Planning and Preparation School Nurse
COMPONENT Level of Performance INEFFECTIVE DEVELOPING EFFECTIVE HIGHLY EFFECTIVE
1a:
Demonstrating
medical knowledge
and skills in nursing
techniques
Nurse demonstrates little understanding
of medical knowledge and nursing
techniques.
Nurse demonstrates basic
understanding of medical knowledge
and nursing techniques.
Nurse demonstrates understanding of
medical knowledge and nursing
techniques.
Nurse demonstrates deep and thorough
understanding of medical knowledge
and nursing techniques.
1b:
Demonstrating
knowledge of child
and adolescent
development
Nurse displays little or no knowledge of
child and adolescent development
Nurse displays partial knowledge of
child and adolescent development.
Nurse displays accurate understanding
of the typical developmental
characteristics of the age group, as well
as exceptions to the general patterns.
In addition to accurate knowledge of
the typical developmental
characteristics of the age group and
exceptions to the general patterns,
nurse displays knowledge of the extent
to which individual students follow the
general patterns.
1c:
Establishing goals for
the nursing program
appropriate to the
setting and the
students served
Nurse has no clear goals for the nursing
program, or they are inappropriate to
either the situation of the age of the
students.
Nurse’s goals for the nursing program
are rudimentary and are partially
suitable to the situation and age of the
students.
Nurse’s goals for the nursing program
are clear and appropriate to the
situation in the school and to the age of
the students.
Nurse’s goals for the nursing program
are highly appropriate to the situation
in the school and to the age of the
students and have been developed
following consultations with students,
parents, and colleagues.
1d:
Demonstrating
knowledge of
government,
community, and
district regulations
and resources
Nurse demonstrates little or no
knowledge of governmental regulations
and resources for students available
through the school or district.
Nurse displays awareness of
governmental regulations and
resources for students available
through the school or district, but no
knowledge of resources available more
broadly.
Nurse displays awareness of
governmental regulations and
resources for students available
through the school or district and some
familiarity with resources external to
the school.
Nurse’s knowledge of governmental
regulations and resources for students
is extensive, including those available
through the school or district and in the
community.
1e:
Planning the nursing
program for both
individuals and groups
of students, integrated
with the regular
school program
Nursing program consists of a random
collection of unrelated activities,
lacking coherence or an overall
structure.
Nurse’s plan has a guiding principle
and includes a number of worthwhile
activities, but some of them don’t fit
with the broader goals.
Nurse has developed a plan that
includes the important aspects of work
in the setting.
Nurse’s plan is highly coherent and
serves to support not only the students
individually and in groups, but also the
broader educational program.
1f:
Developing a plan to
evaluate the nursing
program
Nurse has no plan to evaluate the
program or resists suggestions that such
an evaluation is important.
Nurse has a rudimentary plan to
evaluate the nursing program.
Nurse’s plan to evaluate the program is
organized around clear goals and the
collection of evidence to indicate the
degree to which the goals have been
met.
Nurse’s evaluation plan is highly
sophisticated, with imaginative sources
of evidence and a clear path toward
improving the program on an ongoing
basis.
Revised 8.1.15
DOMAIN 2: Environment School Nurse
COMPONENT Level of Performance INEFFECTIVE DEVELOPING EFFECTIVE HIGHLY EFFECTIVE
2a:
Creating an
environment of
respect and rapport
Nurse’s interactions with at least some
students are negative or inappropriate.
Nurse’s interactions with students are
a mix of positive and negative.
Nurse’s interactions with students are
positive and respectful.
Students seek out the nurse, reflecting
a high degree of comfort and trust in
the relationship.
2b:
Establishing a culture
for health and
wellness
Nurse makes no attempt to establish a
culture for health and wellness in the
school as a whole, or among students or
among teachers.
Nurse’s attempts to promote a culture
throughout the school for health and
wellness are partially successful.
Nurse promotes a culture throughout the
school for health and wellness.
The culture in the school for health and
wellness, while guided by the nurse, is
maintained by both teachers and
students.
2c:
Following health
protocols and
procedures
Nurse’s procedure for the nursing office
are nonexistent or in disarray.
Nurse has rudimentary and partially
successful procedures for the nursing
office.
Nurse’s procedures for the nursing
office work effectively.
Nurse’s procedures for the nursing
office are seamless, anticipating
unexpected situations.
2d:
Supervising health
associates
No guidelines for delegated duties have
been established, or the guidelines are
unclear. Nurse does not monitor
associates’ activities.
Nurse’s efforts to establish guidelines
for delegated duties are partially
successful. Nurse monitors
associates’ activities sporadically.
Nurse has established guidelines for
delegated duties and monitors
associates’ activities.
Associates work independently,
indicating clear guidelines for their
work. Nurse’s supervision is subtle
and professional.
2e:
Organizing physical
space
Nurse’s office is in disarray or is
inappropriate to the planned activities.
Medications are not properly stored.
Nurse’s attempts to create a well-
organized physical environment are
partially successful. Medications are
stored properly but are difficult to
find.
Nurse’s office is well organized and is
appropriate to the planned activities.
Medications are properly stored and
well organized.
Nurse’s office is efficiently organized
and is highly appropriate to the
planned activities. Medications are
properly stored and well organized.
Revised 8.1.15
DOMAIN 3: Delivery of Service School Nurse
COMPONENT Level of Performance INEFFECTIVE DEVELOPING EFFECTIVE HIGHLY EFFECTIVE
3a:
Assessing student
needs
Nurse does not assess student needs,
or the assessments result in
inaccurate conclusions.
Nurse’s assessments of student needs are
perfunctory.
Nurse assesses student needs and
knows the range of student needs in
the school.
Nurse conducts detailed and
individualized assessment of student
needs to contribute to program planning.
3b:
Administering
medications to
students
Medications are administered with
no regard to state or district policies.
Medications are administered by
designated individuals, but signed release
forms are not conveniently stored.
Medications are administered by
designated individuals, and signed
release forms are conveniently stored
and available when needed.
Medications are administered by
designated individuals, and signed
release forms are conveniently stored.
Students take an active role in
medication compliance.
3c:
Promoting wellness
through classes or
classroom
presentations
Nurse’s work with students in
classes fails to promote wellness.
Nurse’s efforts to promote wellness
through classroom presentations are
partially effective.
Nurse’s classroom presentations result
in students acquiring the knowledge
and attitudes that help them adopt a
healthy lifestyle.
Nurse’s classroom presentations for
wellness are effective, and students
assume an active role in the school in
promoting a healthy lifestyle.
3d:
Managing emergency
situations
Nurse has no contingency plans for
emergency situations.
Nurse’s plans for emergency situations
have been developed for the most
frequently occurring situations but not
others.
Nurse’s plans for emergency situations
have been developed for many
situations.
Nurse’s plans for emergency situations
have been developed for many
situations. Students and teachers have
learned their responsibilities in case of
emergencies.
3e:
Demonstrating
flexibility and
responsiveness
Nurse adheres to the plan or
program, in spite of evidence of its
inadequacy.
Nurse makes modest changes in the
nursing program when confronted with
evidence of the need for change.
Nurse makes revisions in the nursing
program when they are needed.
Nurse is continually seeking ways to
improve the nursing program and makes
changes as needed in response to
student, parent, or teacher input.
3f:
Collaborating with
teachers to develop
specialized
educational programs
and services for
students with diverse
medical needs
Nurse declines to collaborate with
classroom teachers to develop
specialized educational programs.
Nurse collaborates with classroom
teachers in developing instructional
lessons and units when specifically asked
to do so.
Nurse initiates collaboration with
classroom teachers in developing
instructional lessons and units.
Nurse initiates collaboration with
classroom teachers in developing
instructional lessons and units, locating
additional resources from outside the
school.
Revised 8.1.15
DOMAIN 4: Professional Responsibilities School Nurse
COMPONENT Level of Performance INEFFECTIVE DEVELOPING EFFECTIVE HIGHLY EFFECTIVE
4a:
Reflecting on practice
Nurse does not reflect on practice, or
the reflections are inaccurate or self-
serving.
Nurse’s reflection on practice is
moderately accurate and objective
without citing specific examples and with
only global suggestions as to how it
might be improved.
Nurse’s reflection provides an accurate
and objective description of practice,
citing specific positive and negative
characteristics. Nurse makes some
specific suggestions as to how the
nursing program might be improved.
Nurse’s reflection is highly accurate
and perceptive, citing specific
examples. Nurse draws on an
extensive repertoire to suggest
alternative strategies.
4b:
Maintaining health
records in accordance
with policy and
submitting reports in
a timely fashion
Nurse’s reports, records, and
documentation are missing, late, or
inaccurate, resulting in confusion.
Nurse’s reports, records, and
documentation are generally accurate, but
are occasionally late.
Nurse’s reports, records and
documentation are accurate and are
submitted in a timely manner.
Nurse’s approach to record keeping is
highly systematic and efficient and
serves as a model for colleagues across
the school.
4c:
Communicating with
families
Nurse provides no information to
families, either about the nursing
program as a whole or about
individual students.
Nurse provides limited though accurate
information to families about the nursing
program as a whole and about individual
students.
Nurse provides thorough and accurate
information to families about the
nursing program as a whole and about
individual students.
Nurse is proactive in providing
information to families about the
nursing program and about individual
students through a variety of means.
4d:
Participating in
professional
community
Nurse’s relationships with
colleagues are negative or self-
serving, and nurse avoids being
involved in school and district
events and projects.
Nurse’s relationships with colleagues are
cordial, and nurse participates in school
and district events and projects when
specifically requested to do so.
Nurse participates actively in school
and district events and projects and
maintains positive and productive
relationships with colleagues.
Nurse makes a substantial contribution
to school and district events and
projects and assumes leadership role
with colleagues.
4e:
Engaging in
professional
development
Nurse does not participate in
professional development activities,
even when such activities are clearly
needed for the development of
nursing skills.
Nurse’s participation in professional
development activities is limited to those
that are convenient or are required.
Nurse seeks out opportunities for
professional development based on an
individual assessment of need.
Nurse actively pursues professional
development opportunities and makes
a substantial contribution to the
profession through such activities as
offering workshops to colleagues.
4f:
Showing
professionalism
Nurse displays dishonesty in
interactions with colleagues,
students, and the public; violates
principles of confidentiality.
Nurse is honest in interactions with
colleagues, students, and the public; does
not violate confidentiality.
Nurse displays high standards of
honesty, integrity, and confidentiality
in interactions with colleagues,
students, and the public; advocates for
students when needed.
Nurse can be counted on to hold the
highest standards of honesty, integrity,
and confidentiality and to advocate for
students, taking a leadership role with
colleagues.
Revised 8.1.15
USD 385 School Nurse Artifact Checklist Form
Domain 1: Planning and Preparation
*Demonstrates medical knowledge & nursing skills *Demonstrates knowledge of child & adolescent development *Establishes appropriate program goals *Demonstrates knowledge of government, community, and district regulations & resources *Plans program for individuals & groups integrated with regular school program *Develops evaluation plan of school nursing program
Domain 2: The Environment *Establishes environment of respect and rapport *Establishes culture for health & wellness *Follows health protocols & procedures *Supervises health associates *Organizes physical space
Domain 3: The Delivery of Service *Assesses student needs *Administers medications to students *Manages emergency situations *Demonstrates flexibility & responsiveness *Collaborates with teachers to develop specialized programs and services for students with diverse medical needs
Domain 4: Professional Responsibilities *Reflects on practice * Maintains health records & submits in timely fashion *Communicates with families *Participates in professional community *Engages in professional development *Shows Professionalism School Nurse Reflection Form Required
School Nurse ____________________________________ School________________________________
Administrator ____________________________________ Grades_______________________________
The school nurse will share a minimum of 4 artifacts as evidence for any of Domains 1-4.
__________________________________
School Nurse Signature
Date _______________________
__________________________________
Evaluator Signature Date _______________________
Revised 8.1.15
USD 385 School Nurse Evaluation Summary Form
School Nurse____________________________ School __________________________ ________________
Administrator ____________________________ Grades ____ ______ Date of Evaluation______________
DOMAIN 1: PLANNING AND PREPARATION
Ineffective Developing Effective Highly Effective Demonstrating medical knowledge and skills in nursing techniques Demonstrating knowledge of child and adolescent development Establishing goals for the nursing program appropriate to the setting and the students served Demonstrating knowledge of government, community, and district regulations and resources Planning the nursing program for both individuals and groups of students, integrated with the regular school program Developing a plan to evaluate the nursing program Comments
DOMAIN 2: THE ENVIRONMENT
Ineffective Developing Effective Highly Effective Creating an environment of respect and rapport Establishing a culture for health and wellness Following health protocols and procedures Supervising health associates Organizing physical space Comments:
Revised 8.1.15
USD 385 School Nurse Evaluation Summary Form
DOMAIN 3: DELIVERY OF SERVICE
Ineffective Developing Effective Highly Effective Assessing student needs Administering medications to students Promoting wellness through classes or classroom presentations Managing emergency situations Demonstrating flexibility and responsiveness Collaborating with teachers to develop specialized educational programs and services for students with diverse medical needs Comments:
DOMAIN 4: PROFESSIONAL RESPONSIBILITIES
Ineffective Developing Effective Highly Effective Reflecting on practice Maintaining health records in accordance with policy and submitting reports in a timely fashion Communicating with families Participating in professional community Engaging in professional development Showing professionalism Comments:
Revised 8.1.15
USD 385 Nurse Evaluation Summary Form
Domain 1 & Domain 4 Domain 2 & Domain 3
Summative Rating: ___________________________
Explanation of Nurse Domain Summative Rating KSDE requires that a final summative rating be determined and reported annually to KSDE. (Marks from Domains 1 + 4 as well as from Domains 2 + 3 will serve as the baseline from which the criteria below have been established) Highly Effective: A minimum of 6 marks in the Highly Effective category and no marks in the Developing and Ineffective categories. Effective: A minimum of 6 marks in the High Effective and Effective categories and no marks in the Ineffective category. Developing: A minimum 6 marks in the Developing and Ineffective categories but, not more than 2 marks in the Ineffective category OR 1 Ineffective mark regardless of other ranks Ineffective: A minimum of 3 marks in the Ineffective category, regardless of other ranks
Revised 8.1.15
Domain 1+4 Domain 2+3 Final
Highly Effective Highly Effective Highly Effective
Highly Effective Effective Highly Effective
Effective Highly Effective Highly Effective
Effective Effective Effective
Effective Developing Effective
Developing Effective Effective
Developing Developing Developing
Developing Ineffective Developing
Ineffective Developing Developing
Ineffective Ineffective Ineffective
Revised 8.1.15
USD 385 Nurse Evaluation Summary Form
Additional Comments by the Evaluator (if any): Comments by the Nurse (if any): An evaluation conference has been held. The Nurse’s signature may not necessarily imply agreement with the
evaluation content. _______________________________ Date_____________________ Evaluator Signature _______________________________ Date_____________________ Nurse Signature
Note: Original copy of this document will become part of personnel file at District Office.
Dates of Observations Observation #1 _________________ Observation #2________________
