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<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">
<html>
<head>
<meta content="text/html; charset=ISO-8859-1" http-equiv="content-type">
<title>Union Gospel Mission (UGM) Salem Work Therapy Evaluation</title>
<style type="text/css">
body {
color: #000;
background: #fff;
width: 100%;
margin: 0;
padding: 0;
zoom: 100%;
}
</style>
</head>
<body oncontextmenu="return false" ondragstart="return false" onselectstart="return false">
<div style="text-align: center; font-weight: bold; font-family: Arial;">
<img style="width: 180px; height: 90px;" alt="UGM Logo" src="https://wgilreath.github.io/UGM-Logo-2016%20180x90px.png">
<br/>
<br/>
<big><big>Work Therapy Evaluation</big></big>
</div>
<table align="center" border="0">
<tbody>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">About</span> </small>
</legend>
<div style="text-align: center;">
<div style="text-align: left;">
</div>
<form method="POST" action="https://formspree.io/ugmsalemdocs@gmail.com">
<div style="text-align: left;">
<small><span style="font-family: Times;">Last Name: </span> </small>
<input size="30" name="lastname">
<small> <span style="font-family: Times;">First Name: </span> </small>
<input size="30" name="firstname">
<small>
<span style="font-family: Times;">Date: </span>
<input id="date" name="date" size="20">
<script type="text/javascript">
document.getElementById("date").value = new Date().toString().substring(4,16);
</script>
<br/>
</small>
</div>
<br/>
<div style="text-align: justify;">
<div style="text-align: left;">
</div>
<small> <span style="font-family: Times;">Work Assignment: </span>
<input size="60" name="work_assignment">
<br/>
</small>
<br/>
<div style="text-align: left;">
<small><span style="font-family: Times;">Name of Supervisor: </span>
<input size="40" name="supervisor">
<br/>
</small>
</div>
</div>
<small> </small>
<div>
</div>
</div>
<small> </small>
<div style="text-align: center;">
</div>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Instructions</span> </small>
</legend>
<small><u>Every month</u> please score the worker on the following listed skills relevant to their jobs. Provide notes based on your objective observation that will aid the individual in improving his performance and character.<b><b> </b></b></small>
</fieldset>
<small> <b><b>
<br/>
</b></b> </small>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Rating Scale</span></small>
</legend>
<div style="text-align: center;">
<small><small><b><b><b><big> 0 - Unacceptable 1 - Below Expectations 2 - Meets Expectations 3 - Exceeds Expectations</big></b><big> </big></b></b></small>
<br/>
</small>
</div>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Willing to Learn:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Shows interest in mastering the skills and methods necessary to do the job. Is teachable and accepts correction.
<select name="learnablity">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="learnability_comment"></textarea>
<br/>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Dependable:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Looks for a way to continue, rather than looking for an opportunity to stop.
<select name="dependable">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="dependable_comment"></textarea>
<br/>
</fieldset>
<small>
<br/>
</small>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Use of Time:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Can be relied on to regularly show up at assigned work area. Is on time and ready to work. Reponsibly returns from breaks and lunches on time. Uses time wisely. <em>Ephesians 6:7 Work with enthusiasm as though you were working for the Lord rather than for people.</em></small><small><small> </small>
<select name="time_use">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="time_use_comment"></textarea>
<br/>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Quality of Work:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Pursues accuracy and effectiveness. Attempts to be thorough and organized. Shows pride in work. Is neat and maintains a clean work area. Produces equal to their ability. <em>Colossians 3:23 Whatever you do, work at with all of your heart, as working for the Lord, not for men.</em>
<select name="quality">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="quality_comment"></textarea>
<br/>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Cooperation with Supervisor:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Responds to all supervision in a positive and constructive manner. Adapts well to changes in responsibilities. Is surrendered, humble, and respectful to authority. <em>Phillipians 2:3-4 Humbly consider others better than yourselves...look not only to your own interests.</em>
<select name="cooperation">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="cooperation_comment"></textarea>
<br/>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Relationships with Others:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Is willing to cooperate and is tactful and courteous. Works well with others. Willing to communicate. Resolves conflict appropriately. Exhibits traits of a servant's heart. Does not have to be the focus of attention. Understands teamwork. <em>Philippians 2:2 ...then make my joy complete by being like-minded, having the same love, being one in spirit and purpose. </em></small><small>
<select name="relates">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="relates_comment"></textarea>
<br/>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Initiative:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Completes work without being constantly reminded. Is creative and a problem solver. Is alert to the needs of surroundings and takes action. Shows developing leadership. <em>Proverbs 20:6 Many a man proclaims his own loyalty. But who can find a trustworthy man?</em>
<select name="initiative">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="initiative_comment"></textarea>
<br/>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Safety/Health Practices Including Dress:</span> </small>
</legend>
<small><span style="text-decoration: underline;"></span>Is concerned with safety rules and use of appropriate protective equipment as directed by work supervisor. Respects the potential danger of tools and machinery. Dresses appropriately for the job and practices personal hygiene.
<select name="safety_health">
<option>0 - Unacceptable</option>
<option>1 - Below Expectations</option>
<option>2 - Meets Expectations</option>
<option>3 - Exceeds Expectations</option>
</select>
<br/>
<br/>
Work Site Supervisor Comments:
<br/>
</small><textarea cols="110" rows="3" name="safety_health_comment"></textarea>
<br/>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend style="font-weight: bold;">
<small><span style="font-family: Verdana;">Evaluate based on C.A.R.E. Standards</span></small>
</legend>
<table style="text-align: left;" border="0" cellpadding="2" cellspacing="2">
<tbody>
<tr>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">Committed</span></small>
</td>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">- Performs job with integrity. Respects and honors others.</span></small>
</td>
</tr>
<tr>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">Attentive</span></small>
</td>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">- Models honesty and courtesy to all. Is a good listener.</span></small>
</td>
</tr>
<tr>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">Responsive</span></small>
</td>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">- Takes resposibility for quality results. Serves effectively.</span></small>
</td>
</tr>
<tr>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">Excellent</span></small>
</td>
<td style="vertical-align: top;">
<small><span style="font-family: Helvetica,Arial,sans-serif;">- Seeks to improve performance while providing excellent service. </span></small>
</td>
</tr>
<small> </small>
</tbody>
<small> </small>
</table>
<small>
<br/>
</small>
</fieldset>
<fieldset>
<legend align="left" style="font-weight: bold;">
<small><span style="font-family: Verdana;">Confirmation</span></small>
</legend>
<div style="text-align: center;">
<span style="font-family: Helvetica,Arial,sans-serif;">
<p>Client has read and understood work therapy evaluation:
<input type="radio" name="confirm_client_read" value="Yes">Yes</input>
<input type="radio" name="confirm_client_read" value="No" checked>No</input>
</p>
</span>
</div>
</fieldset>
</td>
</tr>
<tr>
<td>
<div style="text-align: center;">
<p>
Click the button to submit the work therapy evaluation by e-mail.
</p>
<button type="submit">
Submit Work Therapy Evaluation
</button>
</div>
</form>
<br/>
</td>
</tr>
</div>
</tbody>
</table>
<div align="center">
<table border="0" cellpadding="0" cellspacing="0" width="650">
<tr>
<td width="100%" height="30">
<div align="center">
<font color="#666666" size="2" face="Verdana, Arial, Helvetica, sans-serif">Copyright © 2017 William F. Gilreath. All Rights Reserved.</font>
</div>
</td>
</tr>
</table>
<table border="0" cellpadding="0" cellspacing="0" width="650">
<tr>
<td width="100%" height="30">
<div align="center"> </div>
</td>
</tr>
</table>
</div>
</body>
</html>