Feedback - State Care

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0178 249 7463

Your Feedback

State Care appreciate all feedback and ask that you take 5 minutes to complete the form below.

Please answer the questions from a scale of Unsatisfactory to Excellent.

Unsatisfactory (1), Satisfactory (2), Good (3), Excellent (4)

"*" indicates required fields

Client Name:*

First Last

Ward (if applicable):

Candidate Name:*

First Last

Assignment Date(s):*

Assignment Time(s):*

Role:*

Band:*

The Temporary Worker’s overall performance*

Unsatisfactory	Satisfactory	Good	Excellent

The Temporary Worker’s overall conduct / behaviour*

Unsatisfactory	Satisfactory	Good	Excellent

Relevant Professional and Regulatory Body’s standards of conduct, performance and ethics*

Unsatisfactory	Satisfactory	Good	Excellent

Helpfulness*

Unsatisfactory	Satisfactory	Good	Excellent

Clinical Skill*

Unsatisfactory	Satisfactory	Good	Excellent

Skill Level*

Unsatisfactory	Satisfactory	Good	Excellent

Punctuality*

Unsatisfactory	Satisfactory	Good	Excellent

Appearance*

Unsatisfactory	Satisfactory	Good	Excellent

Preparation for the Shift (i.e. Watch)*

Unsatisfactory	Satisfactory	Good	Excellent

Record Keeping*

Unsatisfactory	Satisfactory	Good	Excellent

Patient Interaction*

Unsatisfactory	Satisfactory	Good	Excellent

Team Interaction*

Unsatisfactory	Satisfactory	Good	Excellent

Does this Temporary Worker have any training needs that you have identified?

Please describe any issues or concerns. For example, where the Temporary Worker may not have provided a high standard of practice and care at all times

Form completed by

Name Title/role Contact details

Office Address

Suite 124, Trent House,
234 Victoria Road, Fenton,
Stoke-on-Trent, ST4 2LW

Contact Information

T: 0178 249 7463
E: info@statecare.uk
E: recruitment@statecare.uk

Opening Hours

Mon-Fri: 9:00am – 5:00pm
Saturday: Closed
Sunday: Closed

Staff Availability:
24 hours a day, 7 days a week

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