PERFORMANCE CHECKLIST

MATERNITY PERFORMANCE CHECKLIST

Name of Student______________________________________________________________________
Year/ Group : _____________________ School Year : ___________________________________
Semester /Term : First Semester _____________ Second Semester __________ Summer
____________

Competency Rate

1 - Unsatisfactory (75- 80) 4 - Very Satisfactory ( 91 – 95)

2 - Fair (81 – 85) 5 - Outstanding (96 – 100)
3 - Satisfactory (86 – 90)

PERFORMANCE CHECKLIST

Gloving Technique

Performance Criteria 5 4 3 2 1 CI’s Remarks

I – KNOWLEDGE (40%)
1. Defines Gloving Technique
2. State the purposes
3. Enumerate special considerations.
4. Identify materials/equipments needed.
5. State preparation of the patient.
6. State the principles/rationale behind
specific action.
II – SKILLS / ABILITY (40%)
1. Remove jewelry, particularly rings.
2. Wash hands.
3. Remove outer wrapper, peeling apart sides
and lay it on a clean, flat surface.
4. Open inner wrapper, touching only the
outside.
5. Secure both flaps open. Identify right and
left glove.
6. Grasp the inner fold with thumb and first
two fingers of non-dominant hand and slip
the hands touching only the inner surface.
7. With dominant gloved hand, slip four
fingers underneath, second glove cuff. Lift
the glove away from the body. Slide the
second hand into the second glove.
8. Adjust fingers of both gloved hand.
 9. Raise gloved hand above waist level.
Gloves Disposal
10. Grasp outside of on cuff with other gloved
hand.
11. Pull glove off, turning it inside out.
12. Take fingers of bare hand and tuck
remaining glove cuff. Pull glove off inside out.
Discard in receptacle.
III – ATTITUDE (20%)
1. Demonstrate preparedness, readiness and
confidence in the performance of the
procedure.
2. Accepts corrections/suggestions and
shows willingness to improve performance.
3. Answers questions politely and tactfully.
4. Shows respect and consideration of the
recipient of care.
5. Observe proper decorum and behave as a
mature student nurse.

Evaluated by: Conforme:

_____________________________ ______________________________
Signature over Printed Name / Date Signature over Printed
Name/Date
Clinical Instructor Student