Performance Appraisal Review Form

(6 Months)

Thank you for choosing MedicsPro Ltd as your preferred agency to work for. Due to the high volume of candidates to
appraise I would like to give you this opportunity to complete this self-appraisal form. Should you require a follow up
call or a meeting please tick the appropriate box and we will contact you. All your comments are valuable and will be
reviewed. The forms will give us a clear indication of any training and development you may require that will help
towards your revalidation and the work you do for us.

Job Title (and Band):

Name:

Date: Last Appraisal Date:

NMC Pin Number: Revalidation Date:

1. Outline the main Clinics/Hospitals/Prisons/Care Homes you have worked at during the last 12 months,
prioritising the establishments with the most hours worked and state if you are Permanent/Full Time/Part
Time/Bank/Agency etc.

Hospital Perm/ FT/PT/Bank/ Agency

1.

2.

3.

4.

5.

2. What is your main speciality or preferred area of work? E.g. A&E, Respiratory wards etc…
1. 2.

3. 4.

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3. How for you would you rate the past 6 months working for Medicspro Ltd?
Good / needs improvement / satisfactory / otherwise and Why?

4. What are your current strengths?

5. What areas of your role you would like to improve in?

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Could you comment on the following?

Your role – Were you fully given orientation on your shift? If so please name the Hospitals/Wards/Care
Homes/Prisons etc:

Are you able to carry out your nursing duties to the best of your ability? E.g. Administering medication, data
input, completion of documentation etc.

Personal Wellbeing and Health – Do you have any medical conditions you would like to disclose.

Non-clinical admin issues (such as Payroll) – Have you ever had any issues? If so, please specify what action was
taken, has it been resolved or still pending?

Are you satisfied with your records keeping and documentation or using the IT system at work?
If not please disclose with which hospitals/wards/care homes/prisons etc you are experiencing difficulties.

Environment – Are you working in a safe and suitable environment?

Complaints – Have you received any complaints from any place of work that you have done recently or have you
any investigations with the NMC or any cautions/convictions on your CRB?

Feedback – Have you received any positive feedback forms? If so, please disclose…

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Reflection statement
I would like you to complete a Reflective Account that you have experienced in the last 6 months working for
MedicsPro Ltd. This could be an example you may want to include as part of your revalidation. Minimum 100
words there is no need to mention names or hospitals.
Reflective Account:

What was the nature of the experience? Set the scene.

What did you learn from this experience?

How did you change or improve your work as a result?

How is this relevant to the code?

Select a theme: Prioritise People –Practice Effectively-Preserve Safety-Promote Professionalism and Trust

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How would you rate your knowledge or capability in the following areas, in terms of your current role? (Score:
1-3 = Poor; 4-6 = Satisfactory; 7-9 = Good; 10 = Excellent)

Clinical Skills
Punctuality
Reliability
Communication skills
Hand writing skills
Honesty/discretion
Coping under pressure
Planning
Timekeeping
Documentation and record keeping
Able to think critically and analytically

Here are some courses that you could do during the next 12 months.

• I.V drug administration

• Mandatory Training
• SOVA level 3
• Interpersonal Skills
• Law ethics accountability and record keeping
• Cannulation and venepuncture
• Blood transfusion
• Medicines Management
• Tracheostomy training
• A&E workshop
• Critical care workshop
• ECG interpretation
• NGT Feeding
• Wound management
• Dementia care

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Objectives for the next year from _______________ to _______________

No Objective: course title Process/steps Support required Target date

To Achieve this

1.

2.

3.

4.

5.

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Do you have a valid MedicsPro/Key Locums ID badge and uniform?

Size uniform

ID Badge expiry date

Appearance

Do you have professional Indemnity?

If yes provide evidence

Name of union/Professional Membership:

e.g. RCN, Unison, Unite etc

Do you have any further comments?

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Are you satisfied with all the contents that you have outlined? YES/ NO
Would you like any of the following?

- A telephone call to follow up

- A meeting at the Birmingham or Woodford Office

- A Skype meeting

- A confirmation email

If so, please email Bilqees.Mauthoor@medicspro.com or Eloise.Hall@medicspro.com or you can call us on 0208 505
6600 ext 227/202

Please put your name in the box below labelled Appraisee and sign and date.

Appraiser (CNM) BM/GD Date:

Bilqees Mauthoor Bilqees Mauthoor

Appraisee/ Candidate

Date of next review meeting: 12 months from today

Office use only:

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