EMPLOYEE COMPETENCY CHECKLIST Annual Assessment Component to the Performance by Klipart

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									                                    EMPLOYEE COMPETENCY CHECKLIST
                                       Annual Assessment Component to the
                                      Performance Management Review Forms

  Employee Name:                                                              Title:

  Department/Unit:                                                            Date Current License/Certification Expires:

                **Indicate completion by placing a checkmark (ü) if required, or write N/A if not required.



                                                         ANNUAL ASSESSMENT

                                           _____         PMF Reviewed and signed

                                           _____         Mandatory Training Requirements

                                           _____         Competency Evaluation
                                                         Elective Training
                                                         Cognitive Abilities
                                                         Technical Skills
                                                         Impersonal Skills

                                           _____         Verification of:
                                                         Licensure/Certification (if required)
                                                         Professional
                                                         CPR
                                           _____         State Drivers License

                                           _____         Annual TB Screening

                                                         Due to Human Resources with PMF.



                                              EMPLOYEE CERTIFICATION

I certify that I have received, reviewed, and understand my responsibilities as described in my Performance Management Form (PMF).

                                                                                                                                __________
Employee Signature                                        Date                         Evaluating Supervisor Signature          Date


I certify that the above named employee           has/      has not completed all of the above requirements applicable to the review
period. If “has not”, what corrective measures are being taken?



I certify that the above named employee            is/           is not competent to provide care to:

                                  Children (ages 0 to 17 years)

                                  Young Adults (ages 18 to 39 years)

                                  Middle Adults (ages 40 to 64 years)

                                  Older Adults (ages 65 and older)
If employee is rated “not competent”, what corrective measures are being taken?



Evaluating Supervisor Signature                           Date                  Reviewing Manager Signature              Date

  CMHC Form # 805
  Revised 6/2005

								
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