Team Member Evaluation Form

Associate Evaluation Form

NAME: ______DATE: ______

Evaluation work sheet completed by ______Doctor/Manager ______

Purpose: To allow an objective evaluation of a Associate’s job performance To be a record-keeping device necessary to maintain an accurate record of the associate’s career development.

Guidelines: A performance review is done on or around an associate’s employment anniversary date. It should be accomplished two times per year The associate and doctor/manager prepare an evaluation individually prior to the joint discussion as to what improvements will be asked to be made following evaluation. Enough time should be allotted for the discussion/review. Best results are attained if it is not held at the end of a workday. This evaluation form is not to b used as a tool for criticism or vengeance, instead as a vehicle, which allows the associate to identify strengths and limitations. Once the limitations are identified, the associate can implement a self-improvement program.

Scoring: 1-3 limited, 4- 5 strengths Fails to meet minimum requirements Rating of 1 Meets minimum requirements Rating of 2 Meets requirements Rating of 3 Exceeds requirements Rating of 4 Rarely equaled Rating of 5 PERSONAL FACTORS

ABILITY TO DEAL WITH PATIENTS TIME EFFECTIVENSS – “Make productive use of Time” _____Remains calm under stressful situation _____Organizes work time and space _____Conversations with patients are about the _____Organizes and maintains instrument trays patient, not about the associate _____Organizes and maintains treatment rooms _____Courteous with patients, other doctor(s) and _____Inventory control of supplies team member(s).

_____Tactful, diplomatic, respectful PUNCTUALITY – “Ability to be prompt”

_____On time for huddles and other meetings TEAM ORIENTED – “Has work together attitude _____On time with assigned tasks (reports, projects) _____Cooperates with assistants & hygienists _____On time after lunch break _____Supports the practice vision & goals _____Assists the assistants in “managing his/her time to _____Encourages others to perform well stay on schedule”

ADAPTABLITY – “Accepts change without SPEECH – “Exhibits control of English language” aggravation” _____Vocabulary/grammar – effective work choice usage _____Flexibility in daily routine of schedule _____Thought clarity – speaks without confusing self and _____Deals well under stress of daily schedule others

_____Attitude remains positive under stress _____Normal Voice tone

_____Refrains from usage of distasteful language NEATNESS/APPEARANCE

_____Maintains a non-clutter work area ATTITUDE

_____Legible record keeping _____Avoids moodiness

_____Maintains well groomed status throughout the _____Presents cheerful image daily workday (dress-uniform, hair, nails, oral hygiene,etc) _____Keeps personal problems out of office

PROFESSIONALISM ACCURACY – “Is detailed oriented” _____Job – Position knowledge _____Is exact and precise _____Maintains confidentiality of patients and practice information _____Avoids repetitive errors CREATIVITY _____Maintains clinical skills thru CE courses _____Comes up with new ideas _____Communication skills with patient, doctor, team _____Formulates workability of ideas, follow thru _____Handling recare system daily check to make sure pt has been in for recent recare _____Unafraid to voice _____Maintains X-ray skills _____Shows initiative at team meetings _____Capable of patient prevention instruction

ABILITY TO TAKE DIRECTIONS _____Maintains positive attitude with patient

_____Does not require repetitive prompting _____Presents treatment recommendations to patients

_____Listens as well as hears without interruptions _____Keeps personal problems out of office

_____Follows instructions without hesitation _____Is exact and precise

_____Maintains firm financial arrangements with STRIVES FOR SELF IMPROVEMENT patients each and every treatment plan _____Seeks out CE and pursues advance certification _____Maintains with patients to avoid the insurance _____Sets personal and practice goals for self traps of only doing what insurance will pay, etc.

_____Accepts constructive criticism with positive _____Preventive health oriented attitude from the doctor of the practice. _____Believes and practices preventive oral hygiene

_____Minimal utilization of “watching” instead of doing SCHEDULING : procedures.

_____Efficient scheduling (perfect day to goal)

_____Organizes and maintains patient recall

_____Organizes and maintains New Patient Calls prior to initial appointment

_____Organizes and maintains Phone skills (awesome customer service conversation during post operative calls

_____Greeting patients with respect, handling ER patients no differently than regular patients Practice Standard of Care Philosophy:

_____Patient motivator and educator to accept treatment

_____Follows treatment recommendations according to the Practice Standard of Care Guidelines

_____Accepts and Supports practice philosophy of dentistry