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Eyecare Specialist Evaluation (NWC)
Please mark the following statements with the most appropriate values. These values show the extent to which you believe your assistant has shown their level of dedication.
What is the Full Name of your Assistant?
*
First
Last
(Please enter the first and last name of your assistant, ex. John Smith)
What Campus did your Assistant Attend?
*
Please select
Riverside
Pomona
Glendale
Pasadena
West Covina
N/A
How many Total Days did the Assistant Attend?
*
(Please enter the number of total days attended, ex. 30)
How many Days was your Assistant Absent?
*
(Please enter the number days absent, ex. 2)
How many Days was your Assistant Tardy?
*
(Please enter the number days tardy, ex. 1)
(PLEASE NOTE: A total of 160 hours is required.)
Practical Experience In:
General Clerical Skills
*
Below Average
Average
Above Average
Excellent
Telephone Technique
*
Below Average
Average
Above Average
Excellent
Making Appointments
*
Below Average
Average
Above Average
Excellent
Knowledge of Banking Procedures
*
Below Average
Average
Above Average
Excellent
Knowledge of Payroll Procedures
*
Below Average
Average
Above Average
Excellent
General Vocabulary & Spelling
*
Below Average
Average
Above Average
Excellent
Use of Ophthalmic & Optometric Terminology
*
Below Average
Average
Above Average
Excellent
Taking Patient Histories
*
Below Average
Average
Above Average
Excellent
Knowledge of Insurance Billing
*
Below Average
Average
Above Average
Excellent
Rx Ordering & Verification
*
Below Average
Average
Above Average
Excellent
Frame Repairs
*
Below Average
Average
Above Average
Excellent
Dispensing & Adjustments
*
Below Average
Average
Above Average
Excellent
Use of Ophthalmic Equipment
*
Below Average
Average
Above Average
Excellent
Contact Lens Patient Instruction
*
Below Average
Average
Above Average
Excellent
Contact Lens Ordering & Verification
*
Below Average
Average
Above Average
Excellent
Computer Knowledge & Skill
*
Below Average
Average
Above Average
Excellent
Personal Traits & Appearance:
Personal Appearance
*
Below Average
Average
Above Average
Excellent
Respect for Others
*
Below Average
Average
Above Average
Excellent
Rapport With Patients
*
Below Average
Average
Above Average
Excellent
Attention to Details
*
Below Average
Average
Above Average
Excellent
Ability to Follow Orders
*
Below Average
Average
Above Average
Excellent
Organizes Work
*
Below Average
Average
Above Average
Excellent
Works Independently
*
Below Average
Average
Above Average
Excellent
Sincere Interest in Optical Field
*
Below Average
Average
Above Average
Excellent
General Comments:
(If you have any other comments please leave them in this box)
Your Name:
*
Prefix
First
Last
Suffix
(Please enter your name, ex. Dr. James Brown)
Your E-Mail Address:
*
(Please enter your e-mail address)
Business Name:
*
(Please enter the business name of the company/hospital you work for, ex. St. Joseph's Hospital)
Your Telephone Number:
*
###
-
###
-
####
(Please enter your telephone number)
