Evaluation Tool for Giving Hepatitis B/DPT Vaccine

Name: Date:
Year Level and Section: Course:

Criterion 4 3 2 1
A. Attitude
1. Wears complete prescribed uniform
2. Neat and well groomed.
3. Observes proper decorum.
4. Demonstrates initiative to learn.
5. Acknowledges criticisms and suggestions. 
B. Knowledge Competencies
1. States objective of the activity.
2. Explains rationale of steps.
3. Uses appropriate terms.
4. Speaks in client’s level of understanding. 
C. Skill Competency 
1. Ask the mother to hold the child across her knees so that his thigh
is facing upwards. Ask her to hold child’s legs.
2. Clean the skin with cotton ball moistened with water and let skin
dry.
3. Place your thumb and index finger on each side of the injection site
and grasp the muscle slightly. Te best injection site is the outer part of
the child’s mid – thigh (Vastus lateralis).
4. Quickly push the needle into the space between your fingers, going
deep into the muscle.
5. Slightly pull the plunger back before injecting to be sure that the
vaccine is not injected into the vein (if using disposable syringes and
needles.)
6. Inject the vaccine. Withdraw the needle and press the injection spot
quickly with a piece of cotton.
Total

Rate the student from 1 to 4 where:

4 is very satisfactory: exhibits competency very satisfactorily

3 is satisfactory: exhibits competency satisfactorily
2 is fair: exhibit competency fairly
1 is needs improvement: needs to improve

Raw Score
Grade Percentage= --------------------------- x 60+40
60

____________________
Student’s Signature

____________________
Evaluator

las/conm