First and Last Name *

Position: *

Date of Self-Evaluation *

Customer service, patient interactions, and meeting patient goals. Scheduled visits are timely with minimal missed visits. *

Accountability for following state & federal regulations, policies, and procedures. Observes ethical and professional conduct at all times i.e respect and punctuality. Integrity in timekeeping, patient visits, and documentation. *

Performs clinical skills accurately, effectively, and competently. Adjusts and modifies provision of care based on patient's needs. *

Observes proper chain of command in reporting referral system. Shows willingness to perform assigned tasks. Verbalizes own strengths, weaknesses, and limitations. *

Utilizes critical thinking and sound decision making. Manifests effective time management and workload organization to facilitate patient care. *

What are your short-term goals at Affinity? *

What are your long-term goals at Affinity? *

Other Comments/Suggestions: