Scale (NOTE: Mastery+ is for Master's prepared RNs) Competent = Competent Level behaviors best describe the nurse

Expert = Expert Level behaviors best describe the nurse Mastery = Mastery Level behaviors best describe the nurse

Mastery+ = Mastery+ Level behaviors best describe the nurse

RN Name:

Uniqname:

Unit/Area:

RSAM Level:

Evaluation Period:

Peer Feedback Form - Flight Nurse Specialist NOTE: DO NOT attempt to fill form in the website. Download (save) it to your computer, flash drive or H drive first. Close the website. Fill saved form only in Adobe Acrobat. Include nurse’s uniqname in file name - ExamplePeer: Type nurse information at right. Referring to Flight Nurse Specialist Behaviors, select ratings for the domain(s) you were requested to evaluate. You are encouraged to provide concrete examples in the text areas. Please complete form within 7 days.

Tip Sheet | Video Save your work - form does not auto-save. Using a Mac?

Please describe a time when you saw me at my very best. What qualities did I display in these domains?

Please provide your input regarding opportunities for my personal and/ or professional growth.

Peer submit instructions: Enter your name/uniqname/role at right. Digitally sign below. Save for your records.

Email the signed form to BOTH: 1) the nurse 2) nurse’s Clinical Nursing Director/Supervisor

Peer Signature: Tip Sheet | Video

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Peer Name:

Uniqname:

Role:

STAFF MEMBER INFORMATION

RN Name:

Uniqname:

Unit/Area:

RSAM Level:

Evaluation Period:

For description of levels/behaviors, refer to: Flight Nurse Specialist Behaviors

Clinical Thinking and Judgment (peer must be an RN)

Reasoning

Skills

Systems Thinking

Systems Thinking

Systems Thinking: Safety

Systems Thinking: Operations

Collaboration/Communication, and Professional Relationships

Facilitator of Learning and Professional Development

Advancing Evidence Based Practice Through Innovation and Research

Contribution

Advocacy

Therapeutic Relationships

Coordination

Response to Diversity

http://www.med.umich.edu/nursing-PDE/rsam/docs/RSAM%20FNS%20Behaviors.pdfhttp://www.med.umich.edu/nursing-PDE/rsam/docs/RSAM%20FNS%20Behaviors.pdfhttp://www.med.umich.edu/NURSING/performance_evaluation/docs/example-peerfeedback-filename.pdfhttp://www.med.umich.edu/NURSING/performance_evaluation/docs/tipSheet-hDrive.pdf#page=2https://nursing.mivideo.it.umich.edu/media/t/1_dy1p5c6hhttp://www.med.umich.edu/NURSING/performance_evaluation/docs/tipSheet-Esign.pdfhttps://nursing.mivideo.it.umich.edu/media/t/1_8c06h04nhttp://www.med.umich.edu/NURSING/performance_evaluation/docs/tipsheet-MacUsers.pdf

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Reasoning: [Select...]Skills: [Select...]Systems Thinking: [Select...]Systems Thinking: Safety: [Select...]Systems Thinking: Operations: [Select...]Collaboration: [Select...]Facilitator: [Select...]EBP: [Select...]Contribution: [Select...]Advocacy: [Select...]Therapeutic Relationships: [Select...]Coordination: [Select...]Diversity: [Select...]Describe a time: Peer, type your response here (replace this text, up to 1000 characters). Font size in text boxes will adjust smaller as you type.Input re growth: Peer Name: Peer Uniqname: RN Name: Uniqname: Unit/Area: RSAM Level: [Select...]Evaluation Period: Peer Role: [Select...]