Healthcare Provider Skill Assessment Survey
Please complete this survey to assess the skills and competencies of the healthcare provider. Your feedback is valuable in supporting continuous improvement.
Healthcare Provider's Full Name
*
First Name
Last Name
Provider's Department or Specialty
*
Please Select
Internal Medicine
Surgery
Pediatrics
Emergency Medicine
Obstetrics & Gynecology
Radiology
Anesthesiology
Family Medicine
Other
Provider's Role
*
Please Select
Physician
Nurse
Physician Assistant
Nurse Practitioner
Therapist
Technician
Other
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator's Full Name
*
First Name
Last Name
Evaluator's Position/Title
*
Please rate the following skill areas for the healthcare provider:
*
Rows
Needs Improvement
Satisfactory
Good
Excellent
Clinical Knowledge
1
2
3
4
Communication Skills
5
6
7
8
Professionalism
9
10
11
12
Teamwork
13
14
15
16
Patient Safety Practices
17
18
19
20
Problem-Solving Skills
21
22
23
24
Overall Performance Rating
*
1
2
3
4
5
How confident are you in this provider's ability to deliver safe and effective care?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Strengths observed in the healthcare provider (please specify):
Areas for improvement (please specify):
Additional comments or recommendations
Submit Assessment
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