QUESTIONNAIRE

ILIGAN MEDICAL CENTER COLLEGE

PALA-O, ILIGAN CITY

Please fill in the questions below, rest assured that all

your answers will be kept confidential. Thank you.

PART 1

Socio-Demographic Profile
Name (Optional):______________________________________

Age:______

Sex: ( ) Male ( ) Female

Civil Status: ( ) Single ( ) Married ( ) Separated ( ) Widow

Hospital Employed:

_____________________________________________________________________________
_

PART 2

Number of Extensions: _____

Legend:

I. 4- Strongly Agree - (Strongly Agrees that you demonstrate this trait)

II. 3-Agree - (Agrees that you demonstrate this trait)
III. 2- Disagree - (Disagrees that you demonstrate this trait)
IV. 1- Strongly Disagree - (Strongly disagrees that you demonstrate this
trait)

RATINGS: 4 3 2 1
I. EXTENSIONS
RLE POLICIES
1. I always attend scheduled orientation.
2. I always come to the hospital ahead of time.
3. I always wear proper duty uniform.
4. I turn my cell phone off during duty hours.
5. I carry out nursing procedures with my C.I’s
permission.
LEGEND:

I. 5- Strongly Agree - (Strongly Agrees that you demonstrate this trait)

II. 4-Agree - (Agrees that you demonstrate this trait)
III. 3- Fairly Agree (Fairly Agrees that you demonstrate this trait)
IV. 2- Disagree - (Disagrees that you demonstrate this trait)
V. 1- Strongly Disagree - (Strongly disagrees that you demonstrate this
trait)

RATINGS: 5 4 3

REQUIREMENTS
1. I always bring my paraphernalias with
me.
2. I always complete the required number
of hours for RLE.
3. I always make my NCP.

4. I always make my SOAPIE.

5. I always present my case study.

NURSING PROCEDURES
CHARTING
1. I apply knowledge in receiving,
interpreting and endorsing reports on
charts.
2. I always chart in correct ink color.

3. I am careful in preventing myself from

making any erasures in the chart.
4. I used correct abbreviations in charting.

5. I keep my patient’s chart with privacy.

BEDSIDE CARE
6. I frequently monitor my patient’s IV
fluid.
7. I assist older patients and children
during ambulation and ROM exercises.
8. I always provide safety to my patient.

9. I provide health teachings to my

patients.
10.I perform bed making and therapeutic
cleaning to my patients’ room.
MEDICATIONS
11.I prepare the medications of my patient
following the 10 rights of drug
administration.
12.I perform proper hygiene and observe
other appropriate infection control
 procedures in preparing medications.
13.I don’t leave the room until my patient
has taken the medications.
14.I know the different nursing
responsibilities of each drug I
administer to my patient.
15.I assess my patient’s condition before
and after giving of medication.
SPECIAL PROCEDURES
16.I observe and follow aseptic technique/
universal precaution before performing
any procedures.
17.I am aware of the purpose and uses of
different facilities and equipments of
the hospital.

1. I efficiently carry out doctor’s orders to

my patient with C.I’s supervision.
2. I always explain the purpose of
performing any procedures to my
patient such as NGT and
Catheterization
3. I observe accuracy in taking my
patient’s vital signs
 QUESTIONNAIRE

ILIGAN MEDICAL CENTER COLLEGE

PALA-O, ILIGAN CITY

JOB PERFORMANCE CHECKLIST

Please fill in the questions below, rest assured that all

your answers will be kept confidential. Thank you.

Legend:

5- Strongly Agree - (Strongly Agrees that you demonstrate this trait)

4-Agree - (Agrees that you demonstrate this trait)
3- Fairly Agree - (Fairly Agrees that you demonstrate this trait)
2- Disagree - (Disagrees that you demonstrate this trait)
1- Strongly Disagree - (Strongly disagrees that you demonstrate this trait)
RATING 5 4 3 2 1

SKILLS

1. Maintains a safe and therapeutic environment by

observing proper waste disposal and infection control.
2. Checks proper functioning and utilization of
equipments and appliances.
3. Demonstrate efficiency and effectiveness in the
execution of nursing functions.
4. Implements nursing care plans by observing age
specific safety and comfort measures.
5. Performs effective assessment techniques in
gathering baseline data(IPPA and Interview)
KNOWLEDGE

1. Integrates nursing process in the utilization of health

teaching learning strategies in the care of patient,
family, significant others and community.
2. Explains the written discharge instructions regarding
patient care to be continued at home.
3. Plans appropriate nursing care based on relevant
assessment findings and nursing diagnosis.
4. Contributes relevant information regarding patient’s
condition reactions to hospitalization and nursing care
rendered for the benefit of quality improvement.

5. Observes strictly principles and specified rules in

carrying out various independent and collaborative
nursing functions.
ATTITUDES

1. Shows determination to achieve personal and

professional goals/aspirations.
2. Observes and adheres strictly to organization policies,
procedures and protocols
3. Establishes rapport with patients, significant others
and members of health team.
4. Possesses positive attitude towards change and
criticisms.
5. Demonstrate good manners and right conduct.

TOTAL: