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/depts/uwhealth/ambulatory-education/staff-driven-competency-model/resources/Sample-Step-3-Employee-Competency-Completion-Form.pdf

20180110

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100

UWHC,UWMF,

Departments & Programs,UW Health,Ambulatory Education,Staff Driven Competency Model,Resources

Example Step 3 Employee Competency Completion

Example Step 3 Employee Competency Completion - Departments & Programs, UW Health, Ambulatory Education, Staff Driven Competency Model, Resources



Step 3
Ongoing Competency Completion Form

Employee Name: Employee ID:

Job Title:
Dept./Unit:

Assessment Period:

This form is to be completed by the employee.
For each of the competency statements listed below, the employee may select which validation method they would like to use. See the
validation method column below for options.
When this form is complete, submit to your manager. Below competencies are to be completed on time and handed into your manager by due
date. This will have a direct impact on your performance evaluation.
Competency Validation Method
Circle Method Used if More Than One Choice
Date Competency
Achieved
Validator Signature
Demonstrates the ability to
apply customer service
principles to everyday work
situations




o Submit 1 customer service
exemplar based on information
from a patient/family member.
May include cards, letters, or
patient satisfaction information
that identifies you by name
o Complete 2 customer service
case studies

Demonstrates the ability to
follow process for appropriate
specimen labeling for all
specimens.

o Completes return
demonstration on specimen
labeling for 3 specimens
o Submits 3 patient charts for
review of specimen labeling.







Course Name
Class Code


I attest that I have independently completed all competency requirements

Employee Signature: ________________________________________________________________ Date: ______________________________
Manager Signature: _________________________________________________________________ Date: ______________________________

If not yet deemed competent, please fill out the action plan with the expected actions of the employee, expected actions of the manager and
due date for completion.















Employee Signature: ________________________________________________________________ Date: ______________________________
Manager Signature: _________________________________________________________________ Date: ______________________________



Return Completed Worksheet to: (manager to also keep hard copy in employee file)
Nursing Education Department (Mail Code 9305)
Ambulatory Education (Mail Code 1035)

Action/Remediation Plan: