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Supervisor’s Signature &Stamp :
Date :
NOTE :
A. Level of Performance
Unable to perform test independently 1
Competence and can perform test 2
independently
Competence and can perform test 3
independently and able to teach others
Not Applicable NA
B. Level of Competence
Competence and able to train (CT) >85%
Competence (C) >75 -85%
Competence with supervision (CS) 50-74%
Need training (NT) <50%
C. Evaluation Method
Observation (O) O
Interview (I) I
Written questionnaire (WQ) WQ
Examine product of work (routine / EQA) EPW
(EPW)
