Caregiver Evaluation Form template designed for caregiver performance assessment, adherence to care plans, and overall job proficiency.
Caregiver Evaluation Form
Agency Information
-
Agency Name: _______________________________________
-
Evaluation Date: ___ / ___ / _______
-
Evaluator’s Name & Title: _______________________________________
Caregiver Information
-
Caregiver Name: _______________________________________
-
Position/Title: _______________________________________
-
Date of Hire: ___ / ___ / _______
-
Evaluation Period: From ___ / ___ / _______ to ___ / ___ / _______
Section 1: Performance Evaluation
Rate the caregiver’s performance in each category according to the following scale:
-
5 - Excellent
-
4 - Good
-
3 - Satisfactory
-
2 - Needs Improvement
-
1 - Unsatisfactory
Evaluation Criteria |
Rating (1-5) |
Comments |
Quality of Care Provided |
||
Consistently meets care plan requirements |
||
Provides attentive, compassionate care |
||
Accurately follows client-specific instructions |
||
Reliability and Punctuality |
||
Regularly arrives on time for shifts |
||
Adheres to scheduled hours and tasks |
||
Communicates appropriately when changes occur |
||
Adherence to Policies & Procedures |
||
Follows agency’s protocols and policies |
||
Complies with HIPAA and privacy regulations |
||
Practices safe and hygienic procedures |
||
Communication Skills |
||
Communicates effectively with clients and staff |
||
Addresses client and family concerns politely |
||
Documents care and updates accurately |
||
Professional Development |
||
Participates in required trainings |
||
Seeks opportunities to improve skills |
||
Adheres to feedback for improvement |
Section 2: Client-Specific Care Adherence
Care Plan Compliance |
Yes/No |
Comments |
|---|---|---|
Has read and understands each assigned client's care plan |
||
Follows specific client dietary or medication needs |
||
Adjusts care approach based on client feedback |
||
Documents any changes or incidents accurately |
Section 3: Skills and Competency Assessment
Competency |
Rating (1-5) |
Comments |
Ability to provide basic personal care |
||
Assists with mobility and transfers safely |
||
Prepares meals that meet nutritional needs |
||
Maintains a clean and safe environment |
||
Observes and reports any changes in client |
Section 4: Strengths and Areas for Improvement
Key Strengths
Areas for Improvement
Section 5: Overall Rating and Recommendations
Overall Performance Rating |
1 - 5 |
Comments |
Overall Job Proficiency |
||
Adherence to Care Plans and Client Needs |
||
Recommendations for Development/Training |
Additional Notes:
Section 6: Caregiver Acknowledgment
I have reviewed the evaluation and discussed it with my supervisor. My signature does not necessarily indicate agreement, but I acknowledge receipt of the evaluation.
-
Caregiver Signature: ___________________________________
-
Date: ___ / ___ / _______
Section 7: Evaluator Signature
-
Evaluator Signature: ___________________________________
-
Date: ___ / ___ / _______
Note: For more customized forms based on your state-specific regulations, you may reach out to us directly. Call 302.888.9172 or email licensing@waivergroup.com for assistance. For additional resources and templates, visit our Policy and Procedure page. Waiver Consulting Group offers expert guidance in regulatory compliance, agency setup, and Medicaid waiver processes across the United States.
This form is crafted to help you systematically assess caregiver performance, ensuring adherence to quality and regulatory standards. If there’s any section you’d like adjusted for your agency’s needs, let us know!