Chesapeake Medical Staffing
Committed to Excellence in Nursing & Allied Health
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Give CMS Your Feedback!
How It Works
Professional Reference Response Form
Clinical & Professional Feedback Request
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:
Name of Facility / Hospital
Unit / Specific setting
Your Work Email
Work Phone Number
Employee Name for whom you are providing feedback
Was this employee Agency or Staff?
Was this employee Part or Full Time?
If any of the below areas are not applicable, please select "meets standards" and include a comment that area was not applicable.
Clinical Competence & Judgment
Flexibility & Adaptability
Utilization of Electronic Medical Records
Electronic Medical Record System Used:
Attitude & Cooperation
Attendance & Punctuality
Is this employee eligible to return to your facility / hospital?
Unable to Comment
Please 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
Nurse Manager / Clinical Superviser Name
By entering your name electronically you agree that this information is correct to the best of your knowledge.