2 Community Health Worker Hands-on Experience

Evaluation Form: Community Health Worker Hands-on Experience
Supervisor's Name: [Supervisor's Name]
Community Health Worker's Name: [CHW's Name]
Date of Evaluation: [Date]
Hours Completed by the Community Health Worker: [Hours]
Please rate the Community Health Worker's performance in the hands-on experience based on the
following criteria:
Knowledge and Understanding:
•
•

Demonstrates understanding of the key concepts and principles related to blood pressure
control and social determinants of health.
Applies the knowledge gained from the course to the hands-on experience effectively.

Rating: [Dropdown rating scale: Excellent, Good, Satisfactory, Needs Improvement]

Health Education Delivery:
•
•

Prepares and delivers health lessons effectively, using clear and concise language.
Engages the audience and effectively communicates important information on blood pressure
control and healthy lifestyle behaviors.

Rating: [Dropdown rating scale: Excellent, Good, Satisfactory, Needs Improvement]

Blood Pressure Screening:
•
•

Demonstrates proficiency in measuring blood pressure accurately and following proper
techniques.
Adheres to safety protocols and maintains confidentiality during screenings.

Rating: [Dropdown rating scale: Excellent, Good, Satisfactory, Needs Improvement]

Referral Process:
•
•

Utilizes the social navigation platform effectively to identify appropriate resources and services
for individuals in need.
Demonstrates understanding of the referral process and follows up with individuals to ensure
they receive the necessary support.

Rating: [Dropdown rating scale: Excellent, Good, Satisfactory, Needs Improvement]

Evaluation Form: Community Health Worker Hands-on Experience
Collaboration and Communication:
•
•

Works collaboratively with the supervisor and other healthcare professionals.
Effectively communicates with individuals, showing empathy and respect.

Rating: [Dropdown rating scale: Excellent, Good, Satisfactory, Needs Improvement]

Professionalism and Ethical Practice:
•
•

Demonstrates professionalism, punctuality, and reliability in fulfilling responsibilities.
Adheres to ethical standards and maintains confidentiality of individuals' health information.

Rating: [Dropdown rating scale: Excellent, Good, Satisfactory, Needs Improvement]

Overall Performance:
•

Assesses the CHW's overall performance in the hands-on experience, considering their
achievement of the learning objectives and ability to apply knowledge effectively.

Rating: [Dropdown rating scale: Excellent, Good, Satisfactory, Needs Improvement]

Comments and Feedback:
[Text box for supervisor's comments and feedback on the CHW's performance]

Development Areas and Action Plan:
[Text box for supervisor's suggestions on areas for improvement and action plan for the CHW's further
development]

Supervisor's Signature: __________________________
Date: __________________________