Caregiver Performance Evaluation Form
Caregiver's Name
First Name
Last Name
Supervisor's Name
First Name
Last Name
Evaluation Date
-
Month
-
Day
Year
Date
Evaluation
Dependability
1
2
3
4
5
Client Focus
1
2
3
4
5
Decision Making
1
2
3
4
5
Communication
1
2
3
4
5
Taking Initiative
1
2
3
4
5
Ongoing Learning
1
2
3
4
5
Commitment
1
2
3
4
5
Excellence
1
2
3
4
5
Positive Attitude
1
2
3
4
5
Likeability
1
2
3
4
5
Adaptability
1
2
3
4
5
Comments/Examples
Performance Indicators
Rate the caregiver according to the following performance indicators.
Exceeds Expectations
Meets Expectations
Needs Improvement
Attendance
1
2
3
Punctuality
4
5
6
Meeting Attendance
7
8
9
Attending Trainings
10
11
12
Emergency Shift Acceptance
13
14
15
Client Compliments
16
17
18
Client Complaints
19
20
21
Job Knowledge
22
23
24
Overall Rating
Exceeds Expectations
Meets Expectations
Needs Improvement
Overall Comments
Supervisor Signature
Submit
Should be Empty: