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Submit timesheets via email: TS MEDISCAN.NET or via fax: 818-401-2126 staﬃng services Employee Name Date Client / Facility Time In Lunch 30/60 Time Out Regular Time Department / Profession Overtime Double Time On Call Call Back Charge Hrs Total Hours: PERFORMANCE EVALUATION (TO BE COMPLETED BY SUPERVISOR) 1 2 3 4 5 N/A Quality of Work: Comments: 4 - Very Good Documentation: 3 - Good Clinical Ability: 2 - Fair Professionalism / Ability: 1 - Poor Attendance / Punctuality: Mediscan Employee Signature 5 - Excellent Date Your signature certifies that all of the above information is true and accurate..
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