EmailMe Form - Dental 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)

Which 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 of days absent, ex. 2)

How many Days was your Assistant Tardy? *

(Please enter the number of days tardy, ex. 1)

(PLEASE NOTE: A total of 180 hours is required.)

Practical Experience In:

Front Office/Secretarial Skills *

Below Average

Average

Above Average

Excellent

Prevention Education *

Below Average

Average

Above Average

Excellent

Coronal Polishing *

Below Average

Average

Above Average

Excellent

Application of Topical Fluoride *

Below Average

Average

Above Average

Excellent

Application of Topical Anesthetic *

Below Average

Average

Above Average

Excellent

Preparation of Syringes *

Below Average

Average

Above Average

Excellent

Oral Surgery Techniques *

Below Average

Average

Above Average

Excellent

Orthodontic Techniques *

Below Average

Average

Above Average

Excellent

Endodontic Techniques *

Below Average

Average

Above Average

Excellent

Sterilization Techniques *

Below Average

Average

Above Average

Excellent

Preparation of Impression Materials *

Below Average

Average

Above Average

Excellent

Study Model Impressions *

Below Average

Average

Above Average

Excellent

Pouring Study Models *

Below Average

Average

Above Average

Excellent

Taking X-Rays *

Below Average

Average

Above Average

Excellent

Developing & Mounting X-Rays *

Below Average

Average

Above Average

Excellent

Assisting at Chairside During Procedures *

Below Average

Average

Above Average

Excellent

Operative Tray Set-Ups *

Below Average

Average

Above Average

Excellent

Use & Care of Instruments *

Below Average

Average

Above Average

Excellent

Use & Care of Equipment *

Below Average

Average

Above Average

Excellent

Preparation of Amalgam *

Below Average

Average

Above Average

Excellent

Preparation of Cements *

Below Average

Average

Above Average

Excellent

Prep. & Cementing of Temporary Crowns *

Below Average

Average

Above Average

Excellent

Matrix Preparation *

Below Average

Average

Above Average

Excellent

Assisting with Dental/Rubber Dam *

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 the Dental 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)