Internal Admin Portal

Annual Performance Evaluations

Complete one performance evaluation every 12 months (or more often per policy) for each active employee and contractor. Use the role shortcuts below to jump directly to the appropriate evaluation form. All submissions are emailed to the HR inbox for filing.

Tip: When possible, complete evaluations during or just after an annual competency review or joint visit so everything stays aligned for survey.

Annual Review Hub

Role-specific forms • CHAP-ready language • Direct to HR inbox

Choose Role to Evaluate

Click a role below to scroll to the correct annual evaluation form. Each form uses a 1–5 rating scale and requires typed signatures from evaluator and employee.

Administrator Alternate Administrator Registered Nurse Pediatric RN Physical Therapist (PT) Occupational Therapist (OT) OT Assistant (OTA) Home Health Aide (HHA) Medical Social Worker (MSW) MSW Assistant

Annual Performance Evaluation – Administrator

Use this form annually to evaluate the Administrator’s performance against Agency, regulatory, and leadership expectations.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Plans, organizes, directs and evaluates Agency operations to ensure adequate and appropriate care and services.
Complies with applicable laws, regulations, payer requirements, and accreditation standards.
Provides fiscal planning, budgeting, and management of operations within established financial parameters.
Implements Governing Body directives and ensures that service policies are developed, implemented, and followed.
Establishes and maintains effective communication with staff, providers, and stakeholders.
Ensures staff development, including orientation, in-service, and performance evaluations.
Directs and monitors Performance Improvement / QAPI activities.
Ensures appropriate staff supervision and qualified personnel are in place during operating hours.
Ensures accuracy of public information, outreach, and marketing materials.
Keeps Governing Body and staff informed of organizational, community, and industry trends.
Participates in evaluation of programs and services and oversees corrective action plans when needed.

This evaluation is emailed to the HR inbox and should be filed in the Administrator personnel record.

Annual Performance Evaluation – Alternate Administrator

Use this form annually to evaluate the Alternate Administrator’s performance in assuming Administrator duties when designated.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Effectively organizes and directs Agency functions in the Administrator’s absence.
Ensures operations support adequate and appropriate care and services.
Complies with applicable laws, regulations, and Agency policies.
Participates in fiscal planning, budgeting, and management of operations within established parameters.
Ensures staff development (orientation, in-service, evaluations) during periods of delegated authority.
Maintains effective communication with staff and leadership.
Participates in Performance Improvement/QAPI, meetings, and committee activities as required.
Keeps Governing Body and Administrator informed of significant trends and issues.

This evaluation is emailed to the HR inbox and should be filed in the Alternate Administrator personnel record.

Annual Performance Evaluation – Registered Nurse

Use this form annually to evaluate the RN’s performance in providing and coordinating skilled nursing care in the home.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Completes initial and ongoing comprehensive assessments (including OASIS, if applicable).
Develops, implements, and revises the plan of care in collaboration with the physician.
Provides skilled nursing interventions safely and according to policy and standards.
Educates clients and caregivers regarding disease process, medications, and self-care.
Documents visits, coordination, and outcomes clearly, accurately, and on time.
Communicates with physicians and interdisciplinary team regarding client status.
Provides required supervision of LVNs/LPNs and Home Health Aides.
Participates in case conferences, PI/QAPI, and staff meetings as required.

This evaluation is emailed to the HR inbox and should be filed in the RN personnel record.

Annual Performance Evaluation – Pediatric Registered Nurse

Use this form annually to evaluate the Pediatric RN’s performance in providing skilled pediatric nursing care in the home.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Conducts initial and ongoing comprehensive pediatric assessments (including OASIS, if applicable).
Initiates and revises the pediatric plan of care as needed.
Provides all services requiring specialized pediatric nursing skills.
Educates pediatric clients and families regarding disease process, self-care, and prevention.
Prepares timely, accurate clinical and progress notes.
Coordinates services with other departments and caregivers.
Acts as liaison with physicians, hospitals, and specialty providers.
Evaluates effectiveness and outcomes of pediatric care.
Provides required supervision of LVNs/LPNs and Home Health Aides.

This evaluation is emailed to the HR inbox and should be filed in the Pediatric RN personnel record.

Annual Performance Evaluation – Physical Therapist

Use this form annually to evaluate the Physical Therapist’s performance in providing skilled PT services in the home.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Provides initial and ongoing PT assessments (including OASIS, if applicable).
Establishes and revises the treatment plan in consultation with the physician.
Provides appropriate interventions to relieve pain, restore function, and maintain maximum performance.
Teaches and counsels clients and families in the PT program and use of assistive devices.
Provides timely, accurate documentation of PT visits and progress.
Communicates with physicians and other team members regarding client status and orders.
Provides required supervision of PT Assistants and Home Health Aides.
Participates in case conferences, PI/QAPI, and staff meetings as required.

This evaluation is emailed to the HR inbox and should be filed in the PT personnel record.

Annual Performance Evaluation – Home Health Aide

Use this form annually to evaluate the Home Health Aide’s performance in providing personal care and supportive services in the home.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Provides personal care (bathing, grooming, toileting) according to the plan of care and standards.
Assists with safe transfers, ambulation, and use of assistive devices.
Follows infection control, standard precautions, and bag technique.
Observes and promptly reports changes in client condition to the supervising nurse/therapist.
Completes aide visit notes accurately, legibly, and on time.
Demonstrates respect, courtesy, and professionalism with clients and families.
Maintains confidentiality and complies with HIPAA requirements.

This evaluation is emailed to the HR inbox and should be filed in the Home Health Aide personnel record.

Annual Performance Evaluation – Occupational Therapist

Use this form annually to evaluate the Occupational Therapist’s performance in providing skilled OT services in the home.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Performs initial and ongoing OT assessments and identifies functional limitations and rehabilitation needs.
Develops and revises the OT plan of care and goals in collaboration with the physician and client/family.
Provides appropriate interventions to improve ADLs, safety, and independence in the home.
Assesses and recommends adaptive equipment and environmental modifications to enhance safety.
Educates clients and caregivers on energy conservation, joint protection, and home programs.
Documents OT visits and progress clearly, accurately, and on time.
Communicates effectively with the interdisciplinary team.

This evaluation is emailed to the HR inbox and should be filed in the OT personnel record.

Annual Performance Evaluation – Occupational Therapist Assistant

Use this form annually to evaluate the OTA’s performance in providing delegated OT services under supervision of the OT.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Provides delegated OT services under the direction and supervision of the OT, within scope of practice.
Implements treatment activities to improve ADLs, safety, and functional abilities.
Instructs clients and caregivers as directed by the OT and reinforces home programs.
Observes and reports client response to treatment and changes in condition to the OT.
Completes visit notes and documentation accurately and on time.
Participates in case conferences and staff meetings as requested.

This evaluation is emailed to the HR inbox and should be filed in the OTA personnel record.

Annual Performance Evaluation – Medical Social Worker

Use this form annually to evaluate the MSW’s performance in providing social work services and case coordination in the home.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Performs psychosocial assessments and identifies social, emotional, and financial needs.
Develops and implements social work plans of care and interventions.
Provides counseling, crisis intervention, and resource referrals to clients and families.
Coordinates with community agencies and payers to obtain needed services.
Documents all contacts, interventions, and outcomes clearly and timely.
Participates in case conferences, care planning, and PI/QAPI activities.

This evaluation is emailed to the HR inbox and should be filed in the MSW personnel record.

Annual Performance Evaluation – Medical Social Worker Assistant

Use this form annually to evaluate the MSW Assistant’s performance in providing delegated social work services under supervision.

Rating scale: 1 = Poor • 2 = Below Average • 3 = Average • 4 = Very Good • 5 = Excellent
Provides delegated social work services under MSW supervision, within scope and policy.
Assists with resource coordination, referrals, and follow-up as directed.
Observes and reports client/family psychosocial issues to the MSW.
Documents contacts and activities accurately and on time.
Maintains confidentiality, professionalism, and appropriate boundaries.

This evaluation is emailed to the HR inbox and should be filed in the MSW Assistant personnel record.