545 Broadway 3rd Floor Brooklyn, NY 11206

(T) 718 305 6700 (F) 718 305 6824

www.advancedcarestaffing.com

We take staffing close to our heart.

Name:

CNA PERFORMANCE EVALUATION

Facility:

Responsibilities Out-

standing

Very Good

Good

Marginal

Poor

Areas for Improvement

I. Clinical Process

Performs tasks necessary to help

resident in personal hygiene.

Assists patients in and out of their

beds, baths or showers, eat or drink,

and keeps the resident’s room clean

at all time.

II. Communication/Interpersonal

Relations

Communicates well with the doc-

tors and nurses regarding pa- tient’s

needs.

Contributes to meeting the emo-

tional, spiritual, and recreational

needs of patients by being aware and

understanding of their needs.

Demonstrates the ability to coop-

erate, work and communicate with

coworkers, supervisors, sub- ordinates

and/or outside contacts.

III. Safety Awareness

Follows safety and conduct rules.

Adherence to company policies and

regulations.

Assumes responsibility for safe

work habits and supports/ rein-

forces policies regarding pa- tient

care and infection control.

Rated By:

Signature:

Name:

Position:

Date:

I certify that this performance assessment has been discussed and explained to me

fully by the rater.

Employee’s Signature:

I certify that this performance assessment was discussed and explained fully to the

employee over the phone:

Discussed by: Date:

Date:

Performs direct care services in accor-

dance with Resident’s Care Plan.