MEDRelief Staffing ~ Clients - Employee Evaluation for Diagnostic Professionals

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Employee Evaluation Forms

Employee Evaluation ~ Diagnostic

As part of our Performance Improvement Program, we would appreciate your time in evaluating our employee’s performance.
Please complete the following Employee Evaluation for an diagnostic professional.
Please click the button at the end of the form to send this form to us or you may print it and fax it to one of the numbers below.

713.596.9770	[local fax]
866.250.5321	[toll-free fax]

Employee Name
Facility Name
Date(s) Assigned	Ex: mm/dd/yy-mm/dd/yy
Facility Supervisor/Evaluator

1 = Poor ... 2 = Needs Improvement ... 3 = Average ... 4 = Above Average ... 5 = Excellent
Technical Performance	Rating
1. Demonstrates knowledge of standard procedure protocols.	1 2 3 4 5
2. Knowledgeable of assigned equipment and able to operate effectively.	1 2 3 4 5
3. Ability to adapt to facility protocol and procedures.	1 2 3 4 5
4. Explains procedure to patient prior to performing the procedure.	1 2 3 4 5
5. Obtains consent for procedure as required by the facility.	1 2 3 4 5
6. Follows facility procedure for paperwork or computer entry of patient data.	1 2 3 4 5
7. Demonstrates ability to process images and/or PACS systems as necessary.	1 2 3 4 5
8. Completes procedures in a timely manner.	1 2 3 4 5
9. Uses appropriate protection to shield patients and self and others as necessary.	1 2 3 4 5
Behavioral/Work Ethics	Rating
1. Reports to work on time for assigned shift.	1 2 3 4 5
2. Complies with facility dress code and name tag is visible.	1 2 3 4 5
3. Maintains a professional attitude towards coworkers and patients at all times.	1 2 3 4 5
4. Demonstrates respect for patient and complies with HIPAA regulations.	1 2 3 4 5
5. Maintains a safe and neat and orderly work environment.	1 2 3 4 5
6. Prioritizes work schedule to maintain good work flow.	1 2 3 4 5
7. Exhibits professional attitude and ethics.	1 2 3 4 5
Would you request this person again to fill your staffing shortages? YES or NO If this response is NO, please identify if the issue is Technical Behavioral or Both Was the MEDRelief Staffing Consultant responsive to your needs? YES or NO We would appreciate any additional comments on our service or personnel.
When complete, please click on the "Submit Evaluation" button below, or print it and fax it to one of the fax numbers above. If you have a staffing need at any time, please call us at 713-270-4836 or 800-342-6704. Thank you!
FOR MEDRELIEF STAFFING USE ONLY Staffing Coordinator evaluation for action:

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