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Developmental Services of Dickson County
Search
Employee Evaluation
07/15/2022
Employee Name
*
First
Last
Employee ID#
Date of Hire
MM slash DD slash YYYY
Date of Evaluation
*
MM slash DD slash YYYY
Effective Date:
*
MM slash DD slash YYYY
Supervisor Name
*
First
Last
Supervisor Email
*
Credited years of Service::
Number of years
Job Title:
*
DSP 90 Day
ECF 90 Day
DSP
DSP 2
ECF
ECF/DSP
Floater
LPN
PA
Changed to Job Title:
DSP 90 Day
ECF 90 Day
DSP
DSP 2
ECF
ECF/DSP
Floater
LPN
PA
Current Team
Trend Setters
Pathways
ECF
Changed to Team
Trend Setters
Pathways
ECF
Current Department
007
010
016
033
036
037
053
056
057
074
076
077
101
110
180
200
201
210
215
216
220
222
223
224
225
226
227
228
229
230
231
240
301
302
305
314
315
318
330
332
333
334
335
339
342
350
351
370
372
400
410
503
601
650
Changed to Department
007
010
016
033
036
037
053
056
057
074
076
077
101
110
180
200
201
210
215
216
220
222
223
224
225
226
227
228
229
230
231
240
301
302
305
314
315
318
330
332
333
334
335
339
342
350
351
370
372
400
410
503
601
650
Current Shift
Changed to Shift
Type of Position
Exempt
Non-Exempt
Salary Non-Exempt
Contract
Scheduled hours per week?
Is employee eligible for benefits?
Yes
No
Current Rate of pay
*
DSP over cap bonus. Current pay rate +raise must equal ($17.00) or more. LPN over cap bonus. Current pay rate +raise must equal ($22.50) or more.
Comments
Attendance
Attendance resulting in corrective actions should have an attached copy of the attendance log for the year.
Attendance Score
*
1. Employee has exceeded 8 call outs for this year. Employee has received multiple corrective actions for these call outs. See attached.
2. Employee has had between 5-8 call outs this year. See attached.
3. Employee has had between 3-5 call outs this year. See attached.
4. Employee has had 1-2 call outs this past year.
5. Employee has had 0 call outs this past year.
Programmatic
Programmatic issues resulting in corrective actions need documentation or back up evidence
Programmatic Score
*
1. Employee Does not meet any or few programmatic criteria. Notes are not in on time, notes are not detailed, or professional, outcomes are not being met. See attached corrective actions.
2. Employee meets some programmatic criteria, Notes are not always in on time, notes are not always detailed, or professional, outcomes are not usually met, See attached corrective actions.
3. Employee meets most programmatic criteria but does not go above and beyond. Notes are usually in on time and professional, some outcomes are met.
4. Employee meets most programmatic criteria. Notes are detailed and professional. Most outcomes are being met.
5. Employee meets all programmatic criteria, Notes in on time, detailed, and professional. All outcomes have been met. Goes above and beyond. Employee follows person centered practices.
Medication Administration
Medication Administration issues resulting in corrective actions need documentation or back up evidence
Medication Administration Score
*
1. Does not have certification in medication administration or does not meet criteria, Or excessive corrective actions.
2. Does not follow the eight rights of medication administration, does not meet criteria, multiple medication errors or corrective actions.
3. Meets basic medication administration guidelines.
4. Meets basic medication administration guidelines, ensures a three-day supply of medications are in the home. Does not have corrective actions.
5. Follows all proper medication administration guidelines, follows the eight rights, ensures medications are picked up on time and ensures a three-day supply is in the home. No corrective actions or medication errors. three-day supply is in the home.
Facilitating Relationships in the community
Facilitating Relationships In The Community Score
*
1. Does not meet criteria for facilitating relationships in the community.
2. Provides very few opportunities to facilitate relationships in the community and/or does not assist in maintaining relationships.
3. Meets basic criteria for facilitating relationships in the community.
4. Meets basic criteria for facilitating relationships in the community and helps to maintain them
5. Follows best practices for facilitating relationships in the community and helping to maintain them.
Above and Beyond
Above and Beyond should be considered an extra bonus and only for extraordinary behavior.
Filling in for call outs
1. N/A
2. Fills in on some occasions, covers call outs but is not always willing/able to cover shifts when requested.
3. Fills in regularly, covers call outs, always willing to stay over or come in when requested.
Reachable by management
1. N/A
2. Returns phone calls during regular business hours and after business hours within 15 minutes or less. Communicates through email or in person without hesitation.
3. Always returns phone calls during regular business hours and after business hours within 15 minutes or less. Communicates through email, text, or in person without hesitation.
Goes above and beyond to ensure the individuals experience a variety of activities
1. N/A
2. Goes above and beyond to ensure the individuals experience a variety of activities in the community, makes sure to include the individuals in meaningful activities. Employee follows most person-centered practices.
3. Goes above and beyond to ensure the individuals experience a variety of activities in the community, setting up events, and makes sure to include the individuals in meaningful activities throughout the year. Employee follows person centered practices.
Attendance 1
Attendance 2
Attendance 3
Attendance 4
Attendance 5
Programmatic 1
Programmatic 2
Programmatic 3
Programmatic 4
Programmatic 5
Medication Administration 1
Medication Administration 2
Medication Administration 3
Medication Administration 4
Medication Administration 5
Facilitating Relationships In The Community 1
Facilitating Relationships In The Community 2
Facilitating Relationships In The Community 3
Facilitating Relationships In The Community 4
Facilitating Relationships In The Community 5
Filling in 2
Filling in 3
Contact with Management 2
Contact with Management 3
Meaningful 2
Meaningful 3
Total
$0.00
Type in Total above
*
example 0.29
Over Cap Bonus?
No
Yes
DSP over cap bonus. Current pay rate +raise must equal ($17.00) or more. LPN over cap bonus. Current pay rate +raise must equal ($22.50) or more.
Hidden
Current rate + raise below cap
Hidden
LPN Current rate + raise below cap
Hidden
Current rate + raise over cap
Hidden
LPN Current rate + raise over cap
Hidden
Total Raise
Hidden
LPN Total Raise
Bonus %
LPN Bonus %
Raise Amount over cap
LPN Raise Amount over cap
Raise Amount over cap total
LPN Raise Amount over cap total
Hidden
Total Rate
Hidden
LPN Total Rate
Under Cap Total Pay Rate
LPN Under Cap Total Pay Rate
Evaluation Skills
Medication Administration Certified?
*
Able to administer medication
Not able to administer medication
1. Did employee wash hands and put on gloves as appropriate?
*
Yes
No
2. Did employee prepare medications according to 8 rights?
*
Yes
No
3. Did employee keep the MAR next to the open medication supply?
*
Yes
No
4. Did employee (prior to administration) read label 3 times by comparing the label to the MAR?
*
Yes
No
5. Did employee prepare person by explaining about medications, for example possible side effects, what used for, etc…?
*
Yes
No
6. Did employee administer medication correctly?
*
Yes
No
7. Did employee remove gloves, wash hands, document med?
*
Yes
No
8. Did the employee explain they would check on person in 30 minutes looking for side effects of adverse reactions?
*
Yes
No
9. Did the employee explain what additional documentation is needed on the MAR for PRN or STAT medications? (employee may need verbal prompt)
*
Yes
No
Skills Comments/concerns:
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
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