CNA PERFORMANCE EVALUATION - Advanced Care Staffing

545 Broadway 3rd Floor

Brooklyn, NY 11206

(T) 718 305 6700

(F) 718 305 6824



THIS FORM IS ONLY FOR YOUR SUPERVISOR

AT YOUR FACILITY TO FILL OUT!

We take staffing close to our heart.

Name:

Facility:

CNA PERFORMANCE EVALUATION

Responsibilities

Outstanding

Very Good

Good

Marginal

Poor

Areas for Improvement

I. Clinical Process

Performs direct care services in accordance with Resident¡¯s Care Plan.

Performs tasks necessary to help

resident in personal hygiene.

Assists patients in and out of their

beds, baths or showers, eat or drink,

and keeps the resident¡¯s room clean

at all time.

II. Communication/Interpersonal

Relations

Communicates well with the doctors and nurses regarding pa- tient¡¯s

needs.

Contributes to meeting the emotional, spiritual, and recreational

needs of patients by being aware and

understanding of their needs.

Demonstrates the ability to cooperate, work and communicate with

coworkers, supervisors, sub- ordinates

and/or outside contacts.

III. Safety Awareness

Follows safety and conduct rules.

Adherence to company policies and

regulations.

Assumes responsibility for safe

work habits and supports/ reinforces policies regarding pa- tient

care and infection control.

Rated By:

Signature:

Name:

Position:

Date:

I certify that this performance assessment has been discussed and explained to me

fully by the rater.

Employee¡¯s Signature:

Date:

I certify that this performance assessment was discussed and explained fully to the

employee over the phone:

Discussed by:

Date:

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