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College of Nursing

Name of Student: ________________________________ Date: ________ Score:_________


Check () the appropriate box representing on how the student performed the procedure for
the graded return demonstration.
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Handwashing (Score_____) pg. 25
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Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
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Gloving (Score_____)
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Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
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Post-Op Bed (Score_____) pg. 31


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Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
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Occupied Bed (Score_____) pg. 32
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Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
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Cleansing Bed Bath (Score_____) pg. 48


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Remarks: ____________________________________________________________________
Students Signature: _________________________
Clinical Instructors/ Preceptors Signature: _________________________
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Feeding Via the Nasogastric Tube (Score_____) pg. 96
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Remarks: ____________________________________________________________________
Students Signature: _________________________
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Clinical Instructors/ Preceptors Signature: _________________________


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Intradermal Injection (Score_____) pg. 111