EmailMe Form - Medical Assistant Evaluation (NWC)

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? *

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 180 hours is required.)

Practical Experience In:

Methods of Sterilization *

Below Average

Average

Above Average

Excellent

Injection Technique *

Below Average

Average

Above Average

Excellent

Examining Room Set-Ups *

Below Average

Average

Above Average

Excellent

Instrumentology & Tray Set-Ups *

Below Average

Average

Above Average

Excellent

Checking Vital Signs *

Below Average

Average

Above Average

Excellent

Taking Electrocardiograms *

Below Average

Average

Above Average

Excellent

Mounting Electrocardiograms *

Below Average

Average

Above Average

Excellent

Bandaging & Casting Techniques *

Below Average

Average

Above Average

Excellent

General Secretarial Skills *

Below Average

Average

Above Average

Excellent

Use of Medical Terminology *

Below Average

Average

Above Average

Excellent

Knowledge of Insurance Forms *

Below Average

Average

Above Average

Excellent

Transcribing using Dictating Machines *

Below Average

Average

Above Average

Excellent

Telephone Techniques *

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

Personality *

Below Average

Average

Above Average

Excellent

Courtesy & Respect *

Below Average

Average

Above Average

Excellent

Alertness *

Below Average

Average

Above Average

Excellent

Cheerfulness *

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

Rapport with Patients *

Below Average

Average

Above Average

Excellent

Sincere Interest in Medicine *

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)