Merit Based Evaluation Form

Employee Name*

Employee Email Address*

Date of Evaluation*

Day Training Infractions

Days Missed/Scheduled Date(s) of Infraction(s)

Days Missed/ Scheduled Evaluator

Tardiness/Returned from break late Date(s) of Infraction(s)

Tardiness/Returned from break late Evaluator

Failure to wear appropriate attire Date(s) of Infraction(s)

Failure to wear appropriate attire Evaluator

Classroom/Clent left unattended Date(s) of Infraction(s)

Classroom/Clent left unattended Evaluator

Inappropriate Interactions Date(s) of Infraction(s)

Inappropriate Interactions Evaluator

2-Way Radio present Date(s) of Infraction(s)

2-Way Radio present Evaluator

Clent eloped from building Date(s) of Infraction(s)

Client eloped from building Evaluator

Leaving group home or classroom unclean Date(s) of Infraction(s)

Leaving group home or classroom unclean Evaluator

Medication Error/Omission Date(s) of Infraction(s)

Medication Error/Omission Evaluator

Dressed client(s) inappropriately Date(s) of Infraction(s)

Dressed client(s) inappropriately Evaluator

Did not follow proper client grooming Date(s) of Infraction(s)

Did not follow proper client grooming Evaluator

Therap Omissions

Failure to document ISP plan Date(s) of Infraction(s)

Failure to document ISP plan Evaluator

Failure to document T-logs Date(s) of Infraction(s)

Failure to document T-logs Evaluator

Failure to document behavior plan Date(s) of Infraction(s)

Failure to document behavior plan Evaluator

Failure to document community outing Date(s) of Infraction(s)

Failure to document community outing Evaluator

Failure to document incident Date(s) of Infraction(s)

Failure to document incident Evaluator

Staff Signature*

Email

This field is for validation purposes and should be left unchanged.