supervisory-visit

Supervisory Visit

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NAME(Required)

JOB TITLE(Required)

SUPERVISOR(Required)

DATE(Required)

EVALUATION PERIOD(Required)

Demonstrates knowledge of CNA/DSW duties(Required)

Follow proper protocols for patient care(Required)

Uses equipment correctly(Required)

Completes tasks accurately(Required)

Follows plan of care(Required)

Job Knowledge & Skills Comments

Maintains high standards of patient care(Required)

Provides consistent care(Required)

Ensures documentation accuracy(Required)

Quality of Work Comments

Treats clients with compassion(Required)

Communicates effectively(Required)

Responds to client needs(Required)

Patient Interaction Comments

Reports to work on time(Required)

Provides advance notice for absences(Required)

Follows facility policies(Required)

Reliability & Attendance Comments

Takes initiative(Required)

Demonstrates professional demeanor(Required)

Follows dress code(Required)

Initiative & Professionalism Comments

Overall Performance/Rating

Provider Employee Signature(Required)

Date(Required)

Support Coordinator Signature(Required)

Date(Required)

Client Signature(Required)

Date(Required)