Self-assessment (Annual Review)

Pre-Review Self-Assessment
Please fill out and submit this self-assessment form prior to your annual review. This is required for all CAREGivers and CNAs.
Care Professional Name*

First NameLast Name
Which training(s) have you attended over the last year?*

Alzheimer's CARE TrainingParkinson'sHIPAA, Abuse, & EmergenciesOther (Please specify below)Other
Additional for Certified Nursing Assistants: Please note any trainings completed in the past year toward your required 12 annual training credits

Please rate yourself in the following areas:*

	Poor	Fair	Average	Good	Excellent
Punctuality
Attendance
Maintaining HIPAA & boundaries
Client relationships
Communication with the office
Attendance for trainings
Clock-in and Clock-out on WellSkyPC or Client's phone
Returning communication from the office in a timely fashion
Record mileage properly
Accepting work offered within availability, driving circle, and preferred total hours
Reading the Care Plans for my Client(s)
Adhering to Care Plan for my Client(s)
Calling the office to discuss any changes needed for Client's Care Plan/Reporting change of condition

Please choose True or False related to the following statements*

	True	False	N/A
I am comfortable with reaching out to the office when I have a question or a concern.
I know who to call when I have a question or a concern.
I feel supported by my Home Instead office.
I am confident in my abilities to connect with my Client(s).
I am creative and adaptable to the needs of my Client(s).
I have never given my person phone number to a Client or Client's family member.
I know how to use the WellSky PC app on my phone.
I know how and when to record mileage for my shifts.
I update my compliance documentation in a timely manner (driver license, auto insurance & registration, CNA license, CPR certification)
I have not had any changes to my driving record or judicial concerns since my date of hire.

My Primary Emergency Contact should be (Name, Relationship, Phone #):*
My Secondary Emergency Contact should be (Name, Relationship, Phone #):*
What was your favorite moment(s) this year with your Client(s)?*
How would you like to see Home Instead change in the coming year?*
What is a goal that you are working toward in your personal or professional life? *
What trainings would you like to see offered at Home Instead?*
Are you interested in becoming a Certified Nursing Assistant or other career path opportunities with Home Instead?*

Already a CNAYes, I would love to become a CNAYes- other opportunitiesNo, I am not interested
I would prefer for my review to be:*

In Person (Warwick office)On the phoneOther
Any additional questions, comments or concerns:
Today's Date*

MonthDayYear
Date
Should be Empty:

Pre-Review Self-Assessment