FNS Peer Input Tool for Annual Evaluation: Contribution
Peer feedback for (RN name):
Directions:
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Evaluatee to send domain portions to peers who evaluatee would like feedback from
Clinical Thinking and Judgment domain is to be completed by another RN
Peers should indicate within the last column the level they feel is appropriate for the Evaluatee on each row
Peers are encouraged to support their views with concrete examples
Peers should complete the peer review within 7 Days and return electronically to the Manager/Designee and Evaluatee
Role Entry / Competent
Expert
Mastery
Peer Should Designate
Appropriate Level Below
DOMAIN: Contribution: Maintains a culture that is supportive and rewards professionalism.
Utilizes appropriate clinical
resources/liaisons
Acts as a clinical resource and/or
liaison within the program
Acts as an expert clinical
resource/liaison beyond the unit
setting, i.e. specialist,
consultant, or resource in any of
the pre-hospital, local, state,
national and international
venues
Maintains the required
certifications
Exceeds certification
requirements in practice
Teaches the certification
requirements
Attendance at internal
committee meetings
Active and contributing member
of internal/and or external
committees
Holds leadership role within the
committees
Attends and participates in
grand rounds discussions
Active participation in case
presentations at grand rounds
Reliably contributes and
presents cases at grand rounds
based on the evidence based
practice model.
Understands there exists
opportunities to promote the
program/institution
Actively participates and
contributes to benefit the
program and institution
Provides expert instruction and
education
Has global awareness of
program direction
Embraces and supports visionary
goals
Understands and utilizes
leadership qualities and
cultivates the strengths and
passions of the team members
to implement initiatives
beneficial to the program and
institution
Is able to utilize and facilitate
educational offerings such as LZ
courses/career development
Visionary for the future
advancement of the program
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Please describe a time when you saw me at my very best. What qualities did I display in this domain?
Please provide your input regarding opportunities for my personal and/or professional growth
I have completed the Peer Feedback Class as required by the UMPNC contract, paragraph 28E, for participation in the
peer review process.
Name:
Date:
Revised 7/2015 Professional Development Framework RSAM Steering Committee/JIT Approved.
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