Competency Assessment Form for __________________

(Competency assessment periods)


Name_________________________________ Job Class___________________________ Work Area_______________


This form is to be completed by the employee. For each of the competency statements listed below, the employee may select

which method of verification method they would like to use to validate their skill in that area. See the method of verification for

details on completion. When this form is complete submit to the area supervisor as indicted.



Method of Verification

Date Completed

Clinical/Technical Domain

Completes DM competency self assessment

Demonstrates the ability to teach the use of the Precision glucometer to include coding, trouble shooting



_____results of self efficacy questionnaire


Nurse observation of teaching Precision glucometer


________________Observers signature


Demonstrates an understanding of diabetes survival skills and its application in the work setting


Completion of Staff Nurses Dive into Diabetes on the Training Events System


Critical Thinking Domain

Demonstrates problem solving skills in caring for the patient with diabetes


Demonstrates an understanding of resources and options available to the patient with diabetes




Completes case study on Training Events System








Interpersonal Domain


Demonstrates adult learning skills when educating a patient




Completion of Teaching/ Learning module for diabetes






The following are a list of the annual training required for this job class. Select one of the Method of Education that you prefer.


Annual Retraining

Method of Education

Date Completed

Diabetes update of changes in DM management

2007 Diabetes update on TES



Insulin / medications

2007 Insulin/medications on TES









This section to be completed by supervisor:

With consideration of the employee performance and competency assessment, this employee is

Competent to perform survival diabetes

Yes No (Not yet deemed competent)

Action Plan:







Employee Signature_________________ Date_______ Supervisor Signature________________ Date________