Candidate Name *

(THE PERSON YOU ARE EVALUATING)

First Name

Last Name

Evaluator Name *

(YOU)

First Name

Last Name

Evaluator Phone Number

(YOUR PHONE NUMBER)

(###)

###

####

What was the relationship between you and the candidate? *

Coworker

Supervisor

Other*

Have you ever served in a supervisory role over the candidate? *

Yes

No

To the best of your knowledge, have there been any concerns and/or disciplinary actions (open or closed) in regards to him/her? does the candidate have any behavioral, physical or mental conditions that could affect his/her work? are there any issues with regard to substance abuse? *

SELECT ONE OPTION

YES*

NO

Rate this candidate's success in his/her training *

On a scale of 1-5 (1 being POOR and 5 being EXCELLENT)

5 (EXCELLENT)

4

3

2

1 (POOR)

Rate this candidate's work habits, including motivation and intiative *

On a scale of 1-5 (1 being POOR and 5 being EXCELLENT)

5 (EXCELLENT)

4

3

2

1 (POOR)

Rate this candidate's communication with staff and patients *

On a scale of 1-5 (1 being POOR and 5 being EXCELLENT)

5 (EXCELLENT)

4

3

2

1 (POOR)

Rate this candidate's communication during stressful situations *

On a scale of 1-5 (1 being POOR and 5 being EXCELLENT)

5 (EXCELLENT)

4

3

2

1 (POOR)

Rate this candidate's ability to maintain patient confidentiality *

On a scale of 1-5 (1 being POOR and 5 being EXCELLENT)

5 (EXCELLENT)

4

3

2

1 (POOR)

Rate this candidate's ability to demonstrate a high level of ethical standards *

On a scale of 1-5 (1 being POOR and 5 being EXCELLENT)

5 (EXCELLENT)

4

3

2

1 (POOR)

Hypothetically, would you (re)hire him/her? *

YES

NO