MEDRelief Staffing ~ Clients - Employee Evaluation

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Employee Evaluation Form

Employee Evaluation

As part of our Performance Improvement Program, we would appreciate your time in evaluating our employee’s performance.
Please complete the following Employee Evaluation.
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
Facility Supervisor/Evaluator's Email Address

1 = Poor ... 2 = Needs Improvement ... 3 = Average ... 4 = Above Average ... 5 = Excellent
Clinical Performance	Rating
1. Demonstrates a clinical proficiency for the assignment.	1 2 3 4 5
2. Ensures accuracy and completeness of work in appropriate timeframe.	1 2 3 4 5
3. Adheres to the policies and procedures of the facility. (HIPAA, National Patient Safety Goals, Infection Control, Risk Management)	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.	1 2 3 4 5
4. Conducts daily activities with the appropriate ethical and legal guidelines.	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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