CMS Professional Reference Response Form Clinical & Professional Feedback An essential component of professional development includes periodic clinical and/or professional feedback. This feedback facilitates communication, provides useful information about job performance, enhances better working relationships, and provides a historical record of performance. Please use the following criteria in providing feedback for the employee. Your time and comments are very much appreciated by CMS as we strive to maintain the highest standards of practice and comply with TJC Health Care Staffing certification requirements. This feedback is confidential and will be submitted securely directly to the CMS office.Nurse Manager / Clinical Supervisor: Please complete the following:Your Name* First Last Your Title*Name of Facility / Hospital*Unit / Specific setting*Your Work Email* Work Phone Number*ExtApplicant InformationEmployee Name for whom you are providing feedback* First Last Employee Certification*Employee Specialty*Was this employee Agency or Staff?*AgencyStaffWas this employee Part or Full Time?*Part TimeFull TimeFrom* Date Format: MM slash DD slash YYYY To* Date Format: MM slash DD slash YYYY Professional BehaviorsIf any of the below areas are not applicable, please select "meets standards" and include a comment that area was not applicable.Clinical Competence & JudgmentExceeds StandardsMeets StandardsNeeds ImprovementFlexibility & AdaptabilityExceeds StandardsMeets StandardsNeeds ImprovementCommunicationExceeds StandardsMeets StandardsNeeds ImprovementTime ManagementExceeds StandardsMeets StandardsNeeds ImprovementUtilization of Electronic Medical RecordsExceeds StandardsMeets StandardsNeeds ImprovementElectronic Medical Record System Used:Attitude & CooperationExceeds StandardsMeets StandardsNeeds ImprovementAttendance & PunctualityExceeds StandardsMeets StandardsNeeds ImprovementIs this employee eligible to return to your facility / hospital?YesNoUnable to commentPlease provide any additional comments about this employee:If you are unable to complete this form due to HR policy, please check the following box: Unable to complete SignatureNurse Manager / Clinical Superviser Name*By entering your name electronically you agree that this information is correct to the best of your knowledge.