UCLA HEALTHCARE INITIAL COMPETENCY VALIDATION SUMMARY Form Must Be

ucla healthcare initial competency validation summary form must be signed and placed in the personnel file employee: (please p

UCLA HEALTHCARE
INITIAL COMPETENCY
VALIDATION SUMMARY
Form must be signed and placed in the personnel file
Employee: (Please Print) _______________________________Title:
__________________ Department /Unit: __________
The above staff member has demonstrated the knowledge and skills
necessary to provide care appropriate to the age of the patients
served on his or her assigned unit. The individual has demonstrated
knowledge of the principles of growth and development over the life
span and possess the ability to assess data reflective of the
patient’s status and interpret the appropriate information needed to
identify each patient’s requirements relative to his or her age
specific needs.
Preceptors: Please sign your initials and date each competency in the
appropriate column as they are completed. Then, sign your full name
and initials below for reference.
AGES SERVED -- Check age groups served
A – Neonates (<30 days)
B – Infants (>= 30 days & <1 year)
C – Pediatrics (>= 1 year & <13 years)
D – Adolescents (>=13 years & < 18 years)
E – Adults (>=18 years & < 65 years)
F – Geriatrics (>=65 years)
O – Not Applicable
Date
Met
Initials
Competencies
Date
Met
Initials
Competencies
Validated by:
Date:
Validated by:
Date:
When Completed
Employee Signature:
Date:
Revision: 9/20/01
512048.doc
competency valid.doc
7/11/01