545 Broadway 3rd Floor Brooklyn, NY 11206 (T) 718 305 6700 (F) 718 305 6824 www.advancedcarestaffing.com We take staffing close to our heart. Name: CNA PERFORMANCE EVALUATION Facility: Responsibilities Out- standing Very Good Good Marginal Poor Areas for Improvement I. Clinical Process Performs tasks necessary to help resident in personal hygiene. Assists patients in and out of their beds, baths or showers, eat or drink, and keeps the resident’s room clean at all time. II. Communication/Interpersonal Relations Communicates well with the doc- tors and nurses regarding pa- tient’s needs. Contributes to meeting the emo- tional, spiritual, and recreational needs of patients by being aware and understanding of their needs. Demonstrates the ability to coop- erate, work and communicate with coworkers, supervisors, sub- ordinates and/or outside contacts. III. Safety Awareness Follows safety and conduct rules. Adherence to company policies and regulations. Assumes responsibility for safe work habits and supports/ rein- forces policies regarding pa- tient care and infection control. Rated By: Signature: Name: Position: Date: I certify that this performance assessment has been discussed and explained to me fully by the rater. Employee’s Signature: I certify that this performance assessment was discussed and explained fully to the employee over the phone: Discussed by: Date: Date: Performs direct care services in accor- dance with Resident’s Care Plan.