Evaluation / Incident (Texas Nurse Connection, Ltd)

Texas Nurse
Connection, Ltd ®

Evaluation / Incident

Please complete all Fields in red.

Please select if Evaluation or Incident:

Employee Name:

Date of Evaluation/Incident:

Next, tell us a little about yourself, so we can contact you if we have any questions.

Your Name:

Client / Facility:

Phone Number:

E-mail:

Address:

City:

State:

Zip Code:

Please rate the employee on the following:

Appearance:

Competency:

Dependability:

Enthusiasm:

Flexibility:

Leadership Ability:

Professionalism:

Quality of Work:

EVALUATION

General comments as to employee's strengths/weaknesses.

Thank you for taking the time to complete employee evaluation.

INCIDENT

Please describe Incident/complaint in detail THIS IS A LEGAL BINDING DOCUMENT ALL ALLEGATIONS FROM INCIDENT/COMPLAINT MUST COME FROM THE PERSON MAKING THE ALLEGATION. Texas Nurse Connection, Ltd will request/require supporting documentation.

Thank you for taking the time to complete Incident Form.

Texas Nurse Connection, Ltd complaint process consists of a review of all written information provided by both Client and employee, including relevant records, if
necessary. Texas Nurse Connection, Ltd will make every attempt to resolve client complaint within 30 days. To assist us in meeting the 30 days, it is important to
provide us all the necessary information and signatures requested on the Complaint Form.

Texas Nurse Connection, Ltd will be available during normal business hours 8:00 AM to 5:00 PM, Monday through Friday. After hours and on holidays and
weekends, the phones will be transferred to on call Coordinator on duty and Client will receive a call list with back-up numbers.

Evaluation / Incident

Texas Nurse Connection, Ltd * 3385 North 3rd Suite 1 * Abilene, Texas 79603
Local: 325-670-0090 * Fax: 325-670-0094 * Toll Free: 1-866- WORKTNC (1-866-967-5862) * Toll Free Fax: 1-866-TNCFAXS * (1-866-862-3297)

Texas Nurse Connection, Ltd is an Equal Opportunity Employer