Employee Performance Evaluation
EMPLOYEE NAME:
HIRE DATE:
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EVALUATION PERIOD:
DATE OF EVALUATION:
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EVALUATORS NAME :
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LAST REVIEW DATE:
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NEXT REVIEW DATE:
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What are the Caregiver’s strengths?
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What major contributions, accomplishments or improvements has the Care Provider made since last evaluation?
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When evaluating individual’s performance, refer to the employee’s job description and contract for
responsibilities and commitments. On the following pages select the rating below that best describes
the Care Provider’s performance in each area. Total up the points for each category and divide by the
number of questions. Grand total all the categories for a single evaluation rating.
1. Unacceptable:
2. Needs Improvement:
3. Acceptable:
4. Excellent:
5. Above and Beyond:
Does not meet job requirements and an Action Plan should be written.
Some job requirements are met and performs below the required level.
Improvement Action Plan should be written.
Consistently performs job requirements at minimum job requirements.
Consistently performs job requirements at maximum requirements.
Always goes above and beyond job requirements.
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RATING
INTEGRITY
Fulfills commitments as agreed to.
Is respectful to every client and their family, treating each with dignity and respect.
Accurately documents services they provided to clients in Care Plan Books.
Maintains client confidentiality.
Is honest whenever working with clients and staff.
Performs job in a positive, cheerful and committed manner.
Is timely, reliable and committed to fulfilling each assignment with excellence.
Total Ratings - Divide By 7 =
RATING
PROFESSIONALISM
Is respectful, considerate and supportive of the company, its staff and clients.
Maintains clean and professional image, wearing the proper uniform requirements on each and every shift in
accordance to their job description.
Displays a supportive team player attitude with respect to the company, company staff, and clients.
Displays respect and listens to supervisors, receptive to constructive feedback.
Maintains confidentiality of clients.
Maintains confidentiality of personal issues and doesn’t discuss them with clients.
Does not discuss wages or other personal employment details with other staff or clients.
Communicates employment concerns and issues with direct supervisor, not care providers or clients.
SubTotal - Divide Total By 8 =
RATING
CONSISTENCY
Promptly returns calls to the office.
Consistently uses time reporting systems for each client/visit/shift.
Promptly communicates client or schedule changes to the office.
Accurately documents each visit in the client care plans with legible, organized notes.
Arrives on time or a few minutes early for each client/visit/shift/assignment.
Schedules are consistently reported to without calling in.
Total Visits in this period: _________
Total # Days Called In : ________________
Has accepted last minute fill in assignments with short notice.
SubTotal - Divide Total By 8 =
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RATING
CARE DELIVERY
Displays actions of compassion and understanding to each client.
Seeks to make a positive difference with each and every client.
Is positive, helpful and happy in providing care services to each client.
Continuously looks for ways to help clients.
Provides services in a way that the client feels they want to be there helping.
SubTotal - Divide Total By 5 =
RATING
TRAINING
Has maintained all training requirements for current license (CNA, LVN, etc).
First Aide & CPR Certified and current.
Participates in monthly training sessions offered by company.
Completed Certification Program (HHA, HCA, CNA, etc.)
Participates in community educational programs.
SubTotal - Divide Total By 5 =
RATING
ABOVE & BEYOND
Received a letter of accolades from company.
Received letter of accolades from a client.
Volunteers and works for a non-profit, charitable organization, event representing the company.
Attend a trade show or event representing the company.
Other: (list)
SubTotal:
SCORE
(Add All Divided Totals)
Add Above & Beyond
Current Pay Rate $
FINAL SCORE
New Pay Rate $
Performance Level
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Improvement Action Plan
With a commitment to ongoing training and improvement, the following Improvement Action Plan clearly specifies the goals
and actions I’ve committed to taking to improve my care services.
The Plan will be reviewed and improvements considered again on (date) ______\________\_______
1.
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2.
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3.
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Supervisor Signature: ________________________________ Date:___________
Care Provider Signature: _____________________________ Date:___________
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