Employee Evaluation Form

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EMPLOYEE EVALUATION FORM

S.A.R.P.H. EEF

(To be completed by pharmacist’s Direct Supervisor)

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nd

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Name of Employee: __________________________

1

2

3

4

Quarter of _______

(year)

Please indicate after the following questions your evaluation of the professional performance of the above named pharmacist. The purpose of this evaluation is to

provide monitoring information to the individual’s S.A.R.P.H. monitor, S.A.R.P.H. officers, PHMP casemanager and/or to the Board of Pharmacy. It is understood by

all parties that this information is confidential and will only be divulged to those persons named in the participant’s S.A.R.P.H. contract and/or, if applicable, pursuant

to a Board Order.

The above named pharmacist: (Rank: 1 = Strongly Disagree; 5 = Strongly Agree)

1.

Has been punctual and regular in attendance to work.

Disagree

1

2

3

4

5

Agree

2.

Has a good attitude about their employment.

Disagree

1

2

3

4

5

Agree

3.

Relates well to other health care professionals.

Disagree

1

2

3

4

5

Agree

4.

Works well with other employees.

Disagree

1

2

3

4

5

Agree

5.

Handles customers/patients and their questions well.

Disagree

1

2

3

4

5

Agree

6.

Overall quality of work performance

_____ Excellent

_____ Good

_____ Fair

_____ Poor

_____ # of Dispensing Errors this quarter

Rate the pharmacist’s over all appearance and general health.

7.

_____ Good _____ Fair

_____ Poor

_____ Deteriorating

8.

Comments (favorable or unfavorable): __________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Employer, Supervisor name and signature: _____________________________________

Pharmacy: ______________________________________ Phone: _________________

Address: ________________________________________________________________

If you have any Questions or Information regarding this form, Please Call or E-mail

Please mail, scan or fax form to Kathie Simpson, Executive Director

S.A.R.P.H. 258 Wolfe Lane, Irwin, PA 15642 Due: March 30, June 30, September 30, December 31.

Phone : (800) 892-4484

May Fax To: (724) 446-7399

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