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​​Instructions for Completing the Performance Checklist

Revised: July 2022

The Performance Checklist is one of the most important documents of the Nurse Aide Training Program and Competency Evaluation Program (NATCEP).  It serves as a transcript and provides evidence that the curriculum was instructed per federal OBRA and PA Act 14 regulations.

The Performance Checklist must:

  • Contain all of the theoretical and practical objectives of the program (in chart form).
  • Be thoroughly and accurately completed by recording the date each student was taught and demonstrated proficiency of nurse aide skills for all OBRA and PA Act 14 objectives. The instructor's signature and date provides authenticity of the student's Performance Checklist.
  • Be retained and kept on file ad infinitum.
  • Be kept confidential.

NOTE: A Performance Checklist must be available for PDE review for every student who attended any portion of a PDE-approved NATCEP.

The Performance Checklist must contain:

  1. Header section on each page:
    • Name of NATCEP program.
    • Mailing address of NATCEP program.
    • Name of the student.
    • Approved 7-digit nurse aide training program code number.
    • Start and end dates of the class or student's end date.
      A heading may not include the student's social security number (student ID is optional).
  2. Body:
    • All of the theoretical and practical objectives of the program, a date when instruction occurred, a date when proficiency of the objective was demonstrated and the outcome as determined by the instructor.  Whenever possible, the proficiency of each objective is demonstrated in the clinical environment by the student and evaluated by the instructor.
    • If the opportunity to assess the nurse aide objective was not possible in the clinical environment, the proficiency of the performance objective(s) must be determined by test question or laboratory skill evaluation.
    • If the objective was demonstrated during a lab session, enter that date and place an asterisk (*) beside it.  If the objective is met by correctly answering a test question, place a plus sign (+) beside the date.  Include a reference note on the last page. (i.e. *= lab and/or + = test question)
    • All spaces requiring a date taught and date demonstrated should record a date. NOTE:  Students under age 18 may only observe the demonstration of a mechanical lift.
    • A date must be entered in each space. A line should not be used to connect dates in columns of various topics and objectives.
  3. Final page:
    • A space for comments.
    • The student's final theory grade (individual quiz grades may be documented) as determined by the program's level of achievement policy and communicated to the student prior to entering the NATCEP.
    • The student's final lab grade as determined by the program's level of achievement policy for the laboratory component of the NATCEP.
    • The student's final clinical grade (Satisfactory/Unsatisfactory, Pass/Fail or numerical grade) as determined by the program's clinical level of achievement policy.
    • Total hours of the approved NATCEP.
    • Date of initial clinical experience.
    • All Instructor's initials and full signature, professional licensure (RN/LPN) and date as attestation that the performance objectives were taught and satisfactorily demonstrated by the student.
    • All program RN supervisors' full signature and date as an attestation that the RN was available and provided general supervision of the LPN instructor while the NATCEP class was in session.
    • The full signature of the student and date.

Completion of the Performance Checklist

  • The Performance Checklist should be thoroughly reviewed to ensure that all sections and spaces have been completed.
  • Each student should be given the original of his or her completed and signed Performance Checklist. This may serve as the student's transcript, if needed, for future employment.

A revised Performance Checklist form may periodically be issued by PDE. Check the PDE​​ Nurse Aide Training website for updates.​