Dental Assistant Evaluation Form

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JOB DESCRIPTION / PERFORMANCE EVALUATION POSITION TITLE: DENTAL ASSISTANT EMPLOYEE NAME: REPORTS TO: DEPARTMENT: Dental EMPLOYMENT STATUS: NON-EXEMPT, HOURLY TYPE OF EVALUATION: Orientation 6 Month SITE: DATE OF HIRE: 3 Month (optional) Annual ASSESSMENT PERIOD: to JOB PURPOSE: To provide technical and clerical assistance to dental providers in provision of clinical dental care.. ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Chairside posture ✔ Chairside instruments ✔ ✔ ✔ ✔ ✔ ✔ ✔ Circle the appropriate weight in pounds 1-10 11-20 21-30 31-40 41-60 61-80 81-100 100 Maximum weight: Circle the appropriate weight in Dental Assistant Job Desc Performance Eval -- May 2013 Page 7 of 10 pounds 1-10 11-20 41-60 61-80 21-30 81-100 31-40 100 Lifting/Carrying: Typical weight: ✔ Circle the appropriate weight in pounds 1-10 11-20 21-30 31-40 41-60 61-80 81-100 100 Maximum weight: Circle the appropriate weight in pounds 31-40 1-10 11-20 21-30 41-60 61-80 81-100 100 Other physical activities Sensory Activities Talking in person Talking on telephone Hearing in person Hearing on telephone Vision for close work ✔ R O C NA Describe any job duty which requires repetition or a unique application of the activity..

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