Employee Evaluation & Wage Review
Employee Date Title Time in Present Position Date of Last Review Attendance Tardies Unexcused Excused Vacation 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 coworkers and management 4. Attitude/Respectfulness - Shows initiative, optimism, and politeness 5. Accepts Criticism - Has ability to learn from suggestions and change behavior 6. Flexibility - Has capacity to respond to changing situations and expectations 7. Policy & Procedures - Follows organization'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. Organizational Skills - Has capacity to stay on track and use time effectively 14. Confidentiality - Does not discuss internal events with coworkers 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 maximize 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 - Maximizes production by scheduling appointments 25. Computer Skills - Effectively navigates all computer programs necessary to complete tasks 26. Telephone Manners - Sounds professional & 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 & EOBs 30. Office Tidiness - Keeps waiting rooms, bathrooms, & 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 & 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 needed 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, sterilizes room/supplies 37. Lab - Completes cases with accuracy & 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