Cincinnati Childrens Hospital Medical Center

Age-Specific Competency Assessment

Name:

Employee Number:

Directions: 1) Identify the age group(s) for which the employee provides care by placing a check (9) in the box next to the age group(s) shown below. 2) For each item in the Performance Criteria list, indicate whether the
employee meets the criteria for each applicable age group by checking 'Yes' or 'No'. 3) Indicate the verification method in the 'Method' column, using the key above the Performance Criteria list. 4) Record the date that the
performance was assessed and your initials. 5) Review the assessment with the employee. 6) Sign and date the form. 7) If needed, the supervisor and employee should jointly develop an action plan for any criteria not met. 8)
Obtain the employee's signature, then sign and date the form in the space provided at the end of the Action Plan section. 9) If you are not the employee's supervisor, submit the form to the supervisor to review and sign the form.

1.

Demonstrates knowledge of normal growth progression (physical,

cognitive, social, emotional) and developmental milestones

2.

Obtains age-specific data (i.e., temperature, pulse, respiration) correctly

3.

Interprets age-specific data (i.e., temperature, pulse, respiration)

accurately and responds appropriately

4.

Uses age-appropriate communication style and language

5.

Takes precautions for safety and injury prevention related to age

6.

Possesses knowledge and skill to use age-appropriate equipment for

assessment & treatments (i.e., appropriate BP cuff, tympanic
thermometer)

7.

Provides physical, emotional, and psycho-social support consistent with

patient's developmental level (i.e., supports infant's head, cuddles infants
and toddlers, uses distraction during painful procedures, sets behavioral
limits)

8.

Has knowledge of age-specific resources within the medical center and

community

9.

Engages the patient, patient's family and significant others in obtaining the
medical history or developing the care plan, as appropriate, based on the
patient's age

10. Recognizes and responds appropriately to signs of abuse or neglect

Employee Signature

Date

Cincinnati Childrens Hospital Medical Center - Version 2.0 March 2002

Evaluator Signature

Date

Supervisor Signature

Date

Date/ Initials

Method

Yes

Date/ Initials

Method

No

No

Adult
(19+ yr.)

Adolescent
(12 - 18 yr.)

Yes

Date/ Initials

Method

No

School Age
(6 - 12 yr.)

Yes

Date/ Initials

Method

No

Date/ Initials

Method

No

Yes

Preschooler
(3 - 5 yr.)

Toddler
(1 - 3 yr.)

Yes

Date/ Initials

Method

Yes

Performance Criteria

No

Infant
(0 - 12 mo.)

CR = Chart Review
V = Verbal explanation
Not Applicable

Method Key:
DO = Direct Observation in clinical setting
S = Simulation in non-clinical setting
T = Written Test or explanation

Action Plan (To be completed by the employee and supervisor, only if performance criteria on page 1 was not met)
Directions: 1) Record the performance criteria not met and associated age group in the table below. 2) For each item, indicate the action steps that the employee will take to develop the competency. Appropriate action steps
may include, but are not limited to, policy reviews, demonstration and practice, training or re-training, or discussion. 3) Record the date that the action plan will be completed in the 'Target Completion Date' column. Action plans
must be completed within 60 days of the initial assessment. 4) Make a copy of the action plan to use for the follow-up assessment.

Criteria Not Met

Age Group

Employee Signature

Action Steps

Date

Target
Completion
Date

Actual
Completion
Date

Supervisor Signature

Initials

Date

Follow-up Assessment (To be completed by the employee's supervisor)

Directions: 1) Complete the follow-up assessment as soon as the employee has completed the action plan outlined above. The follow-up must be completed within 3 months of the initial assessment. 2) Record the completion
date in the 'Actual Completion Date' column of the Action Plan and your initials. 3) Repeat the assessment for the criteria not met, using the form below. 4) Sign and date the form at the end of this section.
5) Send the completed action plan and follow-up assessment to Human Resources.

Employee Signature

Cincinnati Childrens Hospital Medical Center - Version 2.0 March 2002

Date

Supervisor Signature

Date/ Initials

Method

Yes

Method

No

Date/ Initials

Date

No

Adult
(19+ yr.)

Adolescent
(12 - 18 yr.)

Yes

Date/ Initials

Method

No

School Age
(6 - 12 yr.)

Yes

Date/ Initials

Method

No

Date/ Initials

Method

No

Yes

Preschooler
(3 - 5 yr.)

Toddler
(1 - 3 yr.)

Yes

Date/ Initials

Method

Yes

Performance Criteria

No

Infant
(0 - 12 mo.)

CR = Chart Review
V = Verbal explanation
Not Applicable

Method Key:
DO = Direct Observation in clinical setting
S = Simulation in non-clinical setting
T = Written Test or explanation

Additional Comments:

Cincinnati Childrens Hospital Medical Center - Version 2.0 March 2002