BLANKO EVALUASI KINERJA

PERAWAT
IDENTITAS PERAWAT
Nama: ___________________________________________________
Unit : ___________________________________________________

PENILAIAN
Hijau [Baik]
Kuning [Cukup]
Merah [Kurang]

1. KRITERIA PENILAIAN
Skill :
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___
Etika :
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___
Care :
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___
2. KOMITMEN PERBAIKAN
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____
Cirebon, ...................................

(.............................................................
.....)
3. HASIL EVALUASI
Kelebihan
:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___
Kekurangan :
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___
Mengetahui,
Manager Pelayanan Medis

Manager Keperawatan

Manager HRD

drg. Susilawati Sufiatna,

MM

Evi Setianingsih, S.Kep.,

Ns.

Rusdianto, SH