1. Employee Performance Appraisal Form
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Name: _____________________________________________ Date: _________
Employee ID: ___________ Dept.: ________________ Job Title: Staffing Coordinator
Review Type: Quarterly Annual Special
Review Period: ____/____/________ to ____/____/________
Completed by: ________________________________ Title: _________________________
This performance review follows the employees progress over the period assigned by the manager
within this role. This review considers all of the elements of the position as well as how the
employee has meet the assigned expectations. The goal of this review is to help the employee
succeed in their career path with our organization.
Section 1: Evaluation of Responsibilities
This section reviews the employee’sperformance in performing their primary responsibilitiesthroughout the
course of the review period. Ratings are based on data collection to evaluate performance. Comments
provides are used as tools to help improve performance.
Primary Responsibilities Ratings
(highlight selection)
Comments
Providing customer service support to
caregivers and clients: Respond to caregiver and
client calls regarding services, ongoing needs, and other
areas of importance. Must address all areas with
patience, immediacy, and providethe necessary tools to
accomplish a positive resolution.
1 2 3 4 5
Provide care assessments and enter into
client contracts based on services
required: Meet with families and define the services
of the clients to ensure that it is something we can
support and meets their financial needs. Once
established, complete the contract and corresponding
documentation for services required.
1 2 3 4 5
Meet with clients on a weekly basis to
evaluate care and staff services: Ensure
quality service and care for the clients through verbal
and in person visits. Visits are to be documented for
care review and assurance of state standards.
1 2 3 4 5
Meet with Agency Manager on a bi-
weekly basis regarding caregivers and
clients: Review weekly care with Agency Manager to
address changes, successes, and areas of improvements.
These meetings will also be used to plan areas to
improveemployee relations and grow the team.
1 2 3 4 5
Supervise caregivers and handle all
training and disciplinary actions: Manage all
new hiring training, client specific training, and
introduction of new regulation. Responsible for also
connecting with employees on a weekly basis to support
employee’s development, recognize their efforts, and
address training concerns.
1 2 3 4 5

2. Name: _____________________________________________ Date: _________
2
Supervise quarterly and annual trainings:
Responsible for managing regulatory and agency
mandated trainings, documenting employee accuracy,
areas of improvements, and completion.
1 2 3 4 5
With the support of the Agency Manager,
perform annual employee reviews: Meet
with employee evaluating performance throughout the
year, reviewing task completion, goals achievement, and
plans for the coming year.
1 2 3 4 5
Review all care giver notes and timecards
for accuracy and verification: Weekly basis
review caregiver documentation and timecards to
ensure accuracy of agency and regulatory compliances.
1 2 3 4 5
Perform a variety of administrative, data
entry, and office support tasks: New client
data entry and file preparation, biweekly timecard
preparation, preparation of new marketing files, and
other office tasks.
1 2 3 4 5
Provide direct care to patients when
employees are unavailable: Available to
directly care for clients when employees are unavailable
to support care. Ensure that the quality of care
normally provided is maintained.
1 2 3 4 5
Assist with lead generation and new client
development: Must network with local senior
organizations and trade shows to connect with potential
new clients. Responsible for making new contacts
weekly and developing strategies to capture new clients.
1 2 3 4 5
Section 2: Evaluation of Core Competencies
This section reviews core performance aspects related to the position and future development.
Core Competencies Ratings
(highlight selection)
Comments
Communications: Able to provide clear and
focused communications in verbaland written formats. 1 2 3 4 5
Problem Solving/Decision Making: Able to
assess a situation and determine an appropriate
response in a quick and efficient manner that benefits all
parties.
1 2 3 4 5
Training Implementation: Presents learning
materials in a concise manner as well as assesses
learning to ensure employee development.
1 2 3 4 5
Time Management: Able to manage all
responsibilities in a timely manner to meet agency and
regulatory deadlines.
1 2 3 4 5
Quality Management: Ensures all
communications and documents are presented in an
organized and professional manner.
1 2 3 4 5

3. Name: _____________________________________________ Date: _________
3
Leadership: Able to guide employees in a manner
that benefits both the agency and employee’s growth.
Willing to makedifficult decisions to meet agency and
regulatory compliances.
1 2 3 4 5
Teamwork: Works well with other, accepting and
providing support to attain organizational goals. 1 2 3 4 5
Accountability: Accepts responsibility for assigned
tasks and work towards meeting expected goals.
Manages responsibility and delegates tasks as
necessary.
1 2 3 4 5
Relatable: Able to connect with others as an
empathetic listener who can understand and
acknowledge the feelings of others.
1 2 3 4 5
Goal Oriented/High Initiative: Able to define
agency goals and set personal goals to obtain success.
Acknowledges drawbacks and errors, capable of
addressing concerns to quickly get back on track.
1 2 3 4 5
Section 3: Stakeholder Feedback (Peer, Client, and Self-Assessment Results)
This section focuseson actual survey results fromstakeholders in relation to this position. While all results
are summarized for ratings, the comments included are directly from survey reviews.
Core Areas of Feedback Ratings
(highlight selection)
Comments
Customer Service: Professionalism, presentation, and
understanding of the situation.
1 2 3 4 5
Training and Support: Interactive, knowledgeable,
and offers opportunities to develop skills. 1 2 3 4 5
Documentation Management: Keeps all
documentation organized and easily accessible. 1 2 3 4 5
Conflict Resolution: Possesses exceptional skills to
connect with others and find solutions that meet all parties’
expectations.
1 2 3 4 5
Responsiveness and Dependability: Able to
respond to requests immediately and demonstrates follow
through.
1 2 3 4 5

4. Name: _____________________________________________ Date: _________
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Section 4: Developmental Goals and Achievements
This section evaluates results of developmental goals and accomplishments in achieving results.
Developmental Goals Ratings
(highlight selection)
Comments
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Rating Guideline Explanations
1: Unsatisfactory Performance was below expectations in most assigned responsibilities
and core competencies. Employee failed to properly support clients and
employees, causing concerns for safety and incompliance with state
regulations. Corrective action plan will be enacted to help employees
improve their performance.
2: Needs Improvement Performance was inconsistent, with a failure to meet one or more
assigned responsibilities or core competencies. While safety was not a
concern, incompliance of state regulations is a problem. A professional
development plan will be enacted to help employees improve their
performance.
3: Satisfactory Accomplishes tasks as they are set out. Achieves goals and exceeds
expectations in some areas. Quality of work is great but does not always
exceed expectations in every area.
4: Exceeds Expectations Goes above and beyond to accomplish all responsibilities assigned.
Presents a high level of knowledge relating to core competencies.
Achieves all goals and supports others with also achieving their goals.
5: Exceptional Performs at an exceptional level, exceeding all expectations and acts as a
resource for team members. Allows for projects to progress and defines
methods of achieving greater success.

5. Name: _____________________________________________ Date: _________
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Section 5: Future Developmental Goals
These goals are based on the accomplishments and results accumulated from the previous sections. These
goals are created during the performance review process only.
Goals Plan of Action Deadline
Date
Section 6: Comments
This section must NOT be completed priorto the performance review meeting. These comments are to be
freely offered and based on the results presented in the previous sections. Anything addressed is to help
support employee’s performance and development.
Manager’s Comments:
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Employee’s Comments:
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Employee Signature: ___________________________________ Date: _______________
Signing verifies that the employee received a copy of the review form only, not agreement to the results.
Manager’s Signature: ___________________________________ Date: _______________
Human Resources Signature: _____________________________ Date: _______________
HR Name Printed: ____________________________________________