Facility Name and Address

 

Your company employed the above named individual as a:      RN                       LPN                    Surgical Technologist      

 Radiology Technologist      Medical Technologist                                                   

Clinical Specialty                                                                    

Employment Dates:  From                                                                                        To                                                                           

 

Please indicate whether the above information is correct:         Yes     No

Average Patient Caseload                                                   Number of Beds in Unit                                  Charge Duties  Yes  No

 Teaching Facility  Non-Teaching Facility                Number of Beds in Facility                            

Reason for Leaving:                                                                                                                                                                                                                                                                                                                                                                                                                                

 

 

Performance Evaluation:

 

Exceptional

Above Standard

 

Standard

Almost Standard

Below Standard

1.     Demonstrates Competence in Caring for Patients

2.     Provides a Safe & Therapeutic Patient Environment

3.     Implements Coordinated Plan of Patient Care

4.     Adheres to Facility Policy & Procedures

5.     Communicates Appropriately

6.     Completes Accurate Documentation of Patient Care

Professional Attributes:

 

 

 

 

 

7.     Flexibility and Adaptability

8.     Willingness and Ability to Float (if Applicable)

9.     Interest and Enthusiasm

10.   Ability to Communicate with Staff

11.   Attendance and Punctuality

12.   Overall Professionalism

Comments:                                                                                                                                                      

 

                                                                                                                                                                       

 

                                                                                                                                                                       

                                Name                                                                                Title                                                        Date

                                                                                   

                                        Signature

 

This Information Was Obtained by:

 Written Reference

 Verbal Reference

 

 Evaluation

 Recommendation Letter