Forms 2: Evaluation - competency verification form BBP Annual Competency Verification Form August 25, 2010 - August 20,

2011

You will need to complete the following form to be given, if requested, to the lead instructor of your current clinical course or your immediate supervisor. The "Exam Complete" form that you printed out (after you took the quiz) that shows your test results, MUST be stapled behind this verification form. If requested, these forms are required to be turned in prior to or at the day of orientation to the clinical site. If not requested, grade books score of >73% will determine competency.

Name: (print please) _______________________________________ Score: _______________________ (if less than 73%, notify your clinical instructor and retake the learning module).

Circle: UG CAPS SCAN Adjunct Faculty Other

EENAP

MSN

PhD

Full Time Faculty

Date Completed: ___________________________

Score Achieved: (70% minimum-see test results attached) _____________________

Current Clinical Course Enrolled in/Teaching:_____________________

Signature: ______________________________

My signature indicates that the above information is true and accurate.