Home Health Aide Competency Assessment Questionnaire Form
Please complete this assessment to evaluate the competency of a home health aide. All questions relate to professional skills and on-the-job performance.
Professionalism and Work Ethic
*
Needs Improvement
1
2
3
4
Excellent
5
1 is Needs Improvement, 5 is Excellent
Communication Skills
*
Needs Improvement
1
2
3
4
Excellent
5
1 is Needs Improvement, 5 is Excellent
Ability to Follow Care Plans and Instructions
*
Needs Improvement
1
2
3
4
Excellent
5
1 is Needs Improvement, 5 is Excellent
Which of the following tasks has the aide demonstrated competency in? (Select all that apply)
*
Assisting with bathing
Dressing and grooming
Transferring and mobility support
Meal preparation
Medication reminders
Other
Infection Control Practices
*
Needs Improvement
1
2
3
4
Excellent
5
1 is Needs Improvement, 5 is Excellent
How well does the aide respond to emergencies (e.g., falls, sudden illness)?
*
Always responds appropriately
Usually responds appropriately
Sometimes needs guidance
Rarely prepared
Time Management and Punctuality
*
Needs Improvement
1
2
3
4
Excellent
5
1 is Needs Improvement, 5 is Excellent
Which safety practices does the aide consistently demonstrate? (Select all that apply)
*
Proper hand hygiene
Safe lifting/transferring
Use of gloves and PPE
Reporting hazards
Other
Attitude and Interpersonal Skills
*
Needs Improvement
1
2
3
4
Excellent
5
1 is Needs Improvement, 5 is Excellent
Comments or recommendations for further training
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