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Employee Annual Self-Evaluation Form - Clinical
Phone: (248) 395-3777, Fax: (248) 395-3370,
www.hchs.com
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28000 Woodward Ave., Ste 100., Royal Oak, MI 48067
Instructions:
The Self-Evaluation Form is to be completed by the employee being reviewed. Please fully read the descriptors for each factor. Your are encouraged to add comments that pertain to your position accountabilities and performance.
First Name
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Last Name
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Date
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Position
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Home Health Aid (HHA)
Certified Nursing Assistant (CNA)
Licensed Professional Nurse (LPN)
Registered Nurse (RN)
Physical Therapist (PT)
Occupational Therapist (OT)
RT
Other
Other
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Supervisor
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Simone Abner, RN
Gwendolyn Acey, RN
Amanda Stewart, BSN, RN
Kimberly Crite, RN, BS, CBIS
Diane Danna, RN
Julia Depa, RN, CBIS
Marie Hendrix, RN, CBIS
Marc Jeter, RN
Sarah Kareczewski, BSN, RN
Jeanie Kidd, BSN, RN
Alicia Kiselis, BSN, RN
Claude Leblanc, BA, BSN, RN-C
LaTasha Lindemann, RN
Jennifer Long, RN
Pat O'Donahue, RN
Erin Perryman, RN
Marcus Porter, RN, CBIS
Marian Ratton, BSN, RN, JD
Tiffany Rickett, BSN, RN
Martha Shaver, RN, BS, MPA
Emily Yager, BSN, RN, CBIS
Kimberly Wertheimer, BSN, RN
Teresa Daniels, BSN, RN
Tammie Austin, RN
Mical Bey-Shelley, RN
Stephanie Rafe, MSN, RN
Quality of Work - Documentation
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Consistently produces neat and accurate documentation that meets all HealthCall guidelines and deadlines. Requires minimum supervision.
Documentation is very neat and accurate. Requires little supervision.
Documentation is good. Makes very few mistakes.
Documentation is passable, although quality needs improvement.
Frequent errors are noted in documentation; frequently produces work that is not acceptable.
Comments for Quality of Work - Documentation.
Job Knowledge
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Understands all aspects of job, has mastered duties and can carry them out skillfully.
Has a very good knowledge of job functions and performs them well.
Understands most job functions. Requires minimum supervision.
Shows understanding of job but requires help and instruction in some phases of work.
Lacks sufficient understanding of job functions to perform duties effectively.
Comments for Job Knowledge
Interpersonal Skills/Cooperation (applies to client/family/staff)
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Goes out of way to cooperate and assist. Works well with others.
Willing to provide assistance. Alert to the needs of others. Quick to respond.
Works well with others and takes direction. Cooperative.
Usually cooperative. May occasionally exhibit problems in this area.
Poor attitude. Unfriendly and uncooperative when dealing with others.
Comments for Interpersonal Skills/Cooperation
Customer Service.
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Extremely good in dealing with people. Goes out of the way to be helpful and courteous.
Consistently very good with clients. Leaves them with a positive feeling towards HealthCall.
Deals effectively with clients.
Attitude and behavior are not consistently positive.
Frequently rude or disrespectful. Lack of tact.
Comments for Customer Service.
List three areas of outstanding performance
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2.
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3.
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List three areas that need improvement
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2.
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3.
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List one (measurable) goal for the next 12 month period.
Goals can be career development goals as well as goals more directly tied to performance achievement of departmental objectives. Try to write goals that are specific, measurable, attainable, relevant, and time-bound.
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Employee Signature:
If on PC/Laptop - Hold down left mouse button while using mouse to sign your name.
If on Tablet/Phone - Use your finger to sign your name
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clear
Date:
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v1 - 08.09.17