Employee evaluation & wage review
Employee Date Title Time in present position Date of last review Attendance Tardies Unexcused Excused Holiday Scoring EXCEEDS 71-90 MEETS 41-70 NEEDS IMPROVEMENT 0-40 GENERAL Exceeds Meets N.I. 1. Accountability - Accepts responsibility for actions, answerable to consequences 2. Punctuality & attendance - Is rarely absent, arrives punctually, works required hours 3. Cooperation -- Has ability to get along with colleagues and management 4. Attitude/respectfulness - Shows initiative, optimism and politeness 5. Accepts criticism - Has ability to learn from suggestions and change behaviour 6. Flexibility - Has capacity to respond to changing situations and expectations 7. Policy & procedures - Follows organisation’s policies and procedures 8. Completion of assignments - Successfully completes tasks and meets all deadlines 9. Patient interaction - Ensures high-quality care, respects patients’ dignity and confidentiality 10. Quality of work - Is thorough, accurate and neat in work 11. Willingness to develop skills - Desires to take on challenges and learn new techniques 12. Communication skills - Conveys information effectively and efficiently 13. Organisational skills - Has capacity to stay on track and use time effectively 14. Confidentiality - Does not discuss internal events with colleagues 15. Appearance/dress code - Demonstrates a professional and well-kept appearance 16. Appearance of work area - Keeps work area neat and orderly 17. Conflict resolution - Seeks constructive approaches to resolving workplace issues 18. Safety - Contributes to a safe and secure environment by following established procedures 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Employee evaluation & wage review
19. Job knowledge - Demonstrates working knowledge of procedures and health 20. OSHA & HIPPA compliance - Understands regulations and performs tasks appropriately 21. Expense management - Operates and uses supplies to maximise cost efficiency 22. Inventory - Has ability to keep a well-recorded stock of items used and needed 23. Availability - Is available to work any shift as needed by the practice 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1 TOTAL SCORE GENERAL (MAXIMUM 69) FRONT OFFICE Exceeds Meets N.I. 24. Scheduling - Maximises production by scheduling appointments 25. Computer skills - Effectively navigates all computer programs necessary to complete tasks 26. Telephone manners - Sounds professional and successfully uses supplied scripts/techniques 27. Case presentation - Has capacity to accurately prepare and effectively present quotes 28. Patient flow - Has ability to keep schedule on time and limit patient waiting times 29. Insurance/EOBs - Has capacity to read, understand and process insurance breakdowns and EOBs 30. Office tidiness - Keeps waiting rooms, toilets and break room cleaned and stocked 3 3 3 3 3 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 TOTAL SCORE FRONT OFFICE (MAXIMUM 21) BACK OFFICE Exceeds Meets N.I. 31. Clinical skills & duties - Has mastery of clinical procedures and daily maintenance duties 32. Patient preparation - Prepares instruments and room, obtains tests, gains written consent 33. Chairside manner/gentleness - Performs procedures with minimum discomfort to patients 34. Patient treatment - Has ability to accurately complete test results and necessary treatment 35. Charting accuracy - Has capacity to chart from dictation and complete procedure notes 36. Patient dismissal - Provides post-op instructions, hands patient to front, sterilises room/supplies 37. Lab - Completes cases with accuracy and urgency, does not leave cases unmarked or unfinished 3 3 3 3 3 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 TOTAL SCORE BACK OFFICE (MAXIMUM 21) TOTAL OVERALL SCORE (MAXIMUM 90)

Employee evaluation & wage review
Employer’s remarks & recommendations Specific development plan/goals Employee’s comments SALARY REVIEW Current wage per hour New wage per hour Employer signature Date Employee signature Date