EMPLOYEE EVALUATION SHEET
PROBATION PERIOD / ANNUAL
Name of Employee
*
Date of Employment
*
/
Month
/
Day
Year
Position / Title
*
HHA
CNA
Immediate Supervisor
*
ITEM Discussed
Personal appearance / Code of conduct / Behavior
Exceptional
Satisfactory
Punctuality / Visits Frequency compliance
Exceptional
Satisfactory
Attitude to work / Attitude to other workers and staff
Exceptional
Satisfactory
Acknowledgment / Contract-Agreement reviewed
Exceptional
Satisfactory
Attitude-Communication with patients/family
Exceptional
Satisfactory
Responsibility, Job Description Discussion in details,follow physician plan of care, Updates as needed.
Exceptional
Satisfactory
Confidentiality / Privacy / HIPAA guidelines
Exceptional
Satisfactory
Initiative/Duties/Abilities/QA-QI-PI/Agency Evaluation program participation/learning experience
Exceptional
Satisfactory
Morals/Ethics/Courtesy/Conflict of interest
Exceptional
Satisfactory
Ability to record relevant notes, delivery on time,documentation guidelines compliance
Exceptional
Satisfactory
Ability to communicate in legible, professional manner,participation in Case Conference, follow standards precautions, Infection control compliance.
Exceptional
Satisfactory
Knowledge of professional procedures, equipment's-med.device, Participation in continue education, In-services program, Reporting guidelines (Agency, Physician).
Exceptional
Satisfactory
Ability to relate to patient, doctor, community, patients'family and other professionals
Exceptional
Satisfactory
Overall impression regarding quality of care
Exceptional
Satisfactory
Take every other weekend calls
Exceptional
Satisfactory
Accepted new patient : in last three month/ six month / nine months / 1 year
Exceptional
Satisfactory
Substituted for call offs : three month/six month / nine months / 1 year
Exceptional
Satisfactory
Goals Settings
*
Achievement Date
*
/
Month
/
Day
Year
Comments
*
Employee/Contractor Signature
*
Clear
Signature of Administrator/DON/Evaluator
Clear
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