IV Cannulation Competency Assessment Form
Use this form to systematically evaluate a clinician’s competency in IV cannulation.
Clinician Full Name
*
First Name
Last Name
Assessor Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preparation: Hand hygiene and equipment setup
*
1
2
3
4
5
Patient identification and consent
*
1
2
3
4
5
IV site selection and skin preparation
*
1
2
3
4
5
Cannulation technique and insertion
*
1
2
3
4
5
Securing cannula and post-procedure care
*
1
2
3
4
5
Overall competency assessment
*
Competent
Requires Improvement
Not Competent
Assessor Comments
Submit Assessment
Should be Empty: