Employee Evaluation Form
Hygienists/Therapists and Chairside Assistants
Employee name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Position
Appearance
*
Exceeds requirements
Meets Requirements
Does not meet requirements. Improvement needed
N/A
Clean, neat uniform
Hair tied back neatly and off face
Set and meet deadlines
Nails are free from polsih/gel/acrylic to comply with infection control guidelines
Comments if selected "Does not meet requirements. Improvement needed"
Teamwork
*
Exceeds requirements
Meets Requirements
Does not meet requirements. Improvement needed
N/A
Understands patients and patient care is top priority
Keeps instruments and supplies stocked and ready
Works efficiently with others and assists co-workers as necessary
Correct, neat and complete patient entries in computer and file
Completes assigned or given task efficiently AND without negative response
Takes on extra tasks/projects
Does work without having to be asked/uses initiative
Willingness to come in early or stay late
Punctual to work
Leaves personal concerns at home
Prompt with kitchen duties
Cleanliness of oral hygiene room upkept
Overall attitude
Comments if selected "Does not meet requirements. Improvement needed"
Communication
*
Exceeds requirements
Meets Requirements
Does not meet requirements. Improvement needed
N/A
Gives patients undivided attention (eye contact, etc.)
Patient education/instruction of oral hygiene and ortho appliances
Computer chart entries are correct and complete PRIOR to placing patient in out deck
Mini buck correct and updated
Clear communication with FD
Notify Doctors on how they are running for time
Initials of assistant noted at end of every Tx entry.
Correct procedure codes entered for current visit AND next appt.
Correct quote given to patient at appointment and noted in Tx notes.
Summary and delivery of appointment
Concerns addressed/answered to satisfaction
Speed
Comments if selected "Does not meet requirements. Improvement needed"
Procedural skills
*
Exceeds requirements
Meets Requirements
Does not meet requirements. Improvement needed
N/A
Photo efficiency/speed
Photo accuracy/quality
X -ray efficiency/speed
X-ray accuracy/quality
Lab sheets filled in correctly
Checks that enough time has been given for the return of lab work
Sandblasting - Efficiency/Speed
Polishing Wires - Efficiency/Speed
Welding - Efficiency/Speed & Accuracy
Mix impression materials correctly and consistently
Trios scan is efficient and accurate, lab sheets emailed off correctly
Comments if selected "Does not meet requirements. Improvement needed"
Banding/bonding/deband
*
Exceeds requirements
Meets Requirements
Does not meet requirements. Improvement needed
N/A
Effectively explains procedure to patient
Assist operator accurately and with speed
Correct use and application of adhesive/cement materials to appliance
Effectively explains procedure to pt
Ability to choose correct band size
Practices safe and accurate acid-etch technique
Remove all cement/adhesive accurately and efficiently
Tie in lower bonded accurately and efficiently
Correct moisture control methods used
Comments if selected "Does not meet requirements. Improvement needed"
Archwire change
*
Exceeds requirements
Meets Requirements
Does not meet requirements. Improvement needed
N/A
Speed
Engages archwire accurately, efficiently and to completion
Engages speed stops and/or composite ends accurately
Change quicksticks accurately and efficiently
Engage self ligating brackets completely
Comments if selected "Does not meet requirements. Improvement needed"
Infection control
*
Exceeds requirements
Meets Requirements
Does not meet requirements. Improvement needed
N/A
Practising safe infection control procedures
Performs routine handwash at all appropriate times
Has a clear understanding of dirty and clean zones
Wears appropriate personal protective equipment for all procedures
Follows correct sterilisation procedures
Works safely and follows occupational health and safety policies and procedures
Correct use of alcohol hand rub
Comments if selected "Does not meet requirements. Improvement needed"
Additional strengths, development needs or other comments (must be answered in detail)
*
Signature
Submit
Should be Empty: