Teacher:	School:

Grade Level/Subject:	Date:

U=Unsatisfactory	NI=Needs Improvement	P=Proficient	E=Excellent

Domain 1 –Planning and preparation (circle domain rating)	U	NI	P	E
1a. Demonstrating Understanding of Medical Knowledge and Skill in Nursing Practice
1b. Demonstrating Knowledge of Child and Adolescent Development
1c. Establishing Goals for the Nursing Program Appropriate to the Setting and the Students Served
1d. Demonstrates Knowledge Needed to Develop the Nursing Program for Both Individuals and Groups of Students, Integrated With the Regular School Program, Utilizing Community Resources, State Regulations, and District Policies
1e. Developing a Plan to Evaluate the Nursing Program
Domain 2 - The Environment (circle domain rating)	U	NI	P	E
2a. Creating an Environment of Respect and Rapport
2b. Establishing a Culture for Health and Wellness
2c. Establishing and Following Health Protocols and Procedures and Implementing Nursing Practice in an Organized Manner
2d. Managing Expectations for Protocols and Practice
Domain 3 –Delivery of Services (circle domain rating)	U	NI	P	E
3a. Using Knowledge of Student Educational Programs and Services to Collaborate with and Support Different Stakeholders
3b. Using Knowledge of Educational Impact of Prescribed Medication Upon a Student’s Academic Progress
3c. Promoting Wellness Through Classes, Classroom Presentations, and Community Activities
3d. Assessing Student Needs
3e. Demonstrating Flexibility and Responsiveness
Domain 4 – Professional Responsibilities: (circle domain rating)	U	NI	P	E
4a. Reflecting on Nursing Practice
4b. Maintaining Health Records in Accordance with Policy and Submitting Reports in a Timely Fashion
4c. Communicating with Families and Communities and Develops Collaborative Relationships
4d. Growing Individually and Collectively as a Professional
4e. Demonstrating Professionalism, Including Integrity, Advocacy, and Maintaining Confidentiality