Community Health Worker Evaluation Form
Please complete this evaluation to assess the performance and service delivery of the community health worker. Your feedback is valuable and will help improve service quality.
Punctuality: How would you rate the community health worker’s punctuality in attending scheduled visits or meetings?
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Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Communication Skills: How effectively does the community health worker communicate with you and others?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Professionalism: Please rate the community health worker’s professionalism during service delivery.
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Knowledge and Expertise: How would you rate the worker’s knowledge and expertise in their field?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Engagement with Community: How well does the community health worker engage with community members?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Reliability: How would you rate the reliability of the community health worker in fulfilling their responsibilities?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Initiative: Please rate the worker’s ability to take initiative and go beyond basic requirements.
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Teamwork: How well does the community health worker collaborate with other team members?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Overall Performance: Please rate the overall performance of the community health worker.
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Additional Comments or Suggestions
Submit Evaluation
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