Evaluation / Incident
Please complete all Fields in red.
Please select if Evaluation or
Incident:
Employee Name:
Date of Evaluation/Incident:
Next, tell us a little about
yourself, so we can contact
you if we have any questions.
Your Name:
Client / Facility:
Phone Number:
E-mail:
Address:
City:
State:
Zip Code:
Please rate the employee on
the following:
Appearance:
Competency:
Dependability:
Enthusiasm:
Flexibility:
Leadership Ability:
Professionalism:
Quality of Work:
EVALUATION
General comments as to
employee's
strengths/weaknesses
.
Thank you for taking the
time to complete employee
evaluation.
INCIDENT
Please describe
Incident/complaint in detail
THIS IS A LEGAL BINDING
DOCUMENT

ALL
ALLEGATIONS FROM
INCIDENT/COMPLAINT
MUST COME FROM THE
PERSON MAKING THE
ALLEGATION.

Texas Nurse Connection, Ltd
will request/require
supporting documentation.
Thank you for taking the
time to complete Incident
Form.
 
Texas Nurse Connection, Ltd complaint process consists of a review of all written information provided by both Client and employee, including relevant records, if
necessary. Texas Nurse Connection, Ltd will make every attempt to resolve client complaint within 30 days. To assist us in meeting the 30 days, it is important to
provide us all the necessary information and signatures requested on the Complaint Form.
Texas Nurse Connection, Ltd will be available during normal business hours 8:00 AM to 5:00 PM, Monday through Friday.  After hours and on holidays and
weekends, the phones will be transferred to on call Coordinator on duty and Client will receive a call list with back-up numbers.
Evaluation / Incident
Forms
 
 
 
 
 
 
 
 
 
Texas Nurse Connection, Ltd * 3385 North 3rd Suite 1 * Abilene, Texas 79603
Local: 325-670-0090 * Fax: 325-670-0094 * Toll Free: 1-866- WORKTNC (1-866-967-5862) * Toll Free Fax: 1-866-TNCFAXS * (1-866-862-3297)