Does this diagnosis affect the student’s YES NO
ability to safely practice nursing?
If Yes, provide explanation:_________________________________________________
________________________________________________________________________
________________________________________________________________________
Indicate whether the student is able to meet the following cognitive, sensory, affective and psychomotor
performance requirements by indicating “Yes” or “No” next to each technical standard.
YES NO
Critical Thinking
Critical-thinking ability sufficient for
clinical judgment
Identify cause/effect relationships in
clinical situations, develop nursing
care plans
YES NO
Interpersonal
Interpersonal abilities sufficient for
interaction with individuals, families,
and groups from various social,
emotional, cultural, and intellectual
backgrounds
Establish rapport with
patients/clients and colleagues, and
respond appropriately to stressful
situations
YES NO
Communication
Communication abilities sufficient for
verbal and written interaction with others
Explain treatment procedures,
initiate health teaching, and
document and interpret nursing
actions and patient/client responses
YES NO
Mobility
Physical abilities sufficient for
movement from room to room and in
small spaces
Move around in patient's room, work
spaces and treatment areas;
administer cardiopulmonary
procedures
YES NO
Motor Skills
Gross and fine motor abilities sufficient
for providing safe, effective nursing care
Calibrate and use equipment;
position patients/clients
YES NO
Hearing
Auditory ability sufficient for monitoring
and assessing health needs
Hear monitor alarm, emergency
signals, auscultatory sounds and
cries
YES NO
Visual
Visual ability sufficient for observation
and assessment necessary in nursing care
Observe patient/client responses,
including color changes
YES NO
Tactile
Tactile ability sufficient for physical
assessment
Perform palpation, functions of
physical examination and/or those
related to therapeutic intervention
(such as insertion of a catheter)
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