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Submitted URL: https://amnhealthcare.force.com/portal/ptevaluator?id=a1A2I00000Ezjsb#/
Effective URL: https://amnhealthcare.force.com/portal/ptevaluator?id=a1A2I00000Ezjsb
Submission: On January 05 via manual from US — Scanned from DE
Effective URL: https://amnhealthcare.force.com/portal/ptevaluator?id=a1A2I00000Ezjsb
Submission: On January 05 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: pEvaluationForm —
<form class="edit-form ng-pristine ng-invalid ng-invalid-required" name="pEvaluationForm" ng-submit="attestEvaluationInfo(pEvaluationForm)" novalidate="true" role="form">
<div class="ibox float-e-margins" id="reference-panel">
<div class="ibox-title">
<h1>Reference Request</h1>
</div>
<!-- ngIf: editEvaluationInfo.IsReferenceInProgress -->
<div id="formNotSubmitted" ng-if="editEvaluationInfo.IsReferenceInProgress" class="ng-scope">
<div class="ibox-content">
<div class="row"> The individual named below has applied for employment with one of the AMN Healthcare brands and has named you as a reference contact. Please complete all required fields and submit the form by clicking on the submit button.
Your response will be held in the strictest confidence. </div>
</div>
<div class="ibox-heading">
<h4>Requestor Profile<span class="pull-right"><a class="text-muted editLnk" onclick="$('#label-requester').hide(); $('#edit-requester').show();"><i class="fa fa-pencil-square-o "></i> Edit</a></span></h4>
</div>
<div class="ibox-content">
<div class="row" id="label-requester">
<div class="col-md-6">
<label for="name">Name: </label>
<span ng-bind-html="editEvaluationInfo.Candidate.FirstName" class="ng-binding">Lora</span> <span ng-bind-html="editEvaluationInfo.Candidate.MiddleName" class="ng-binding"></span> <span ng-bind-html="editEvaluationInfo.Candidate.LastName"
class="ng-binding">Campbell-East</span>
<br>
<label for="email">Email: </label>
<span ng-bind-html="editEvaluationInfo.Candidate.Email" class="ng-binding">fullerlora5@gmail.com</span>
</div>
<div class="col-md-6">
<label for="profession">Job Category: </label>
<span ng-bind-html="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Discipline__c" class="ng-binding">Nursing</span><br>
<label for="specialty">Profession: </label>
<span ng-bind-html="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Specialty__c" class="ng-binding">Registered Nurse</span><br>
<label for="subspecialty" ng-show="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Sub_Specialty__c != null">Specialty: </label>
<span ng-bind-html="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Sub_Specialty__c" class="ng-binding">Telemetry</span>
</div>
</div>
<ng-form name="requester" class="ng-pristine ng-valid ng-valid-required">
<div class="row" id="edit-requester" style="display:none">
<div class="col-md-6">
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.requester.FirstName.$invalid }">
<label class="control-label" for="FirstName">First Name</label>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="FirstName" ng-model="editEvaluationInfo.Candidate.FirstName" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.requester.FirstName.$invalid">Please enter a First Name</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.requester.LastName.$invalid }">
<label class="control-label" for="LastName">Last Name</label>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="LastName" ng-model="editEvaluationInfo.Candidate.LastName" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.requester.LastName.$invalid">Please enter a Last Name</span>
</div>
<div class="form-group">
<label for="specialty">Email</label><br>
<span ng-bind-html="editEvaluationInfo.Candidate.Email" class="ng-binding">fullerlora5@gmail.com</span>
</div>
</div>
<div class="col-md-6">
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.requester.Profession.$invalid }">
<label class="control-label" for="profession">Job Category</label>
<select class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="Profession"
ng-change="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Specialty__c = null; editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Sub_Specialty__c = null; getSpecialties(editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Discipline__c)"
ng-model="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Discipline__c" ng-options="name for name in professions" required="required">
<option value="0" label="Behavioral Health & Social Services">Behavioral Health & Social Services</option>
<option value="1" label="Chiropractic Providers">Chiropractic Providers</option>
<option value="2" label="Dental Providers">Dental Providers</option>
<option value="3" label="Dietary & Nutrition Services">Dietary & Nutrition Services</option>
<option value="4" label="Emergency Medical Service Providers">Emergency Medical Service Providers</option>
<option value="5" label="Eye and Vision Services Providers">Eye and Vision Services Providers</option>
<option value="6" selected="selected" label="Nursing">Nursing</option>
<option value="7" label="Nursing Support">Nursing Support</option>
<option value="8" label="Pharmacy">Pharmacy</option>
<option value="9" label="Physician Assistants & Advanced Practice Nursing Providers">Physician Assistants & Advanced Practice Nursing Providers</option>
<option value="10" label="Podiatric Medicine & Surgery Service Providers">Podiatric Medicine & Surgery Service Providers</option>
<option value="11" label="Rehabilitation & Respiratory Services">Rehabilitation & Respiratory Services</option>
<option value="12" label="Speech, Language & Hearing Services">Speech, Language & Hearing Services</option>
<option value="13" label="Student, Health Care">Student, Health Care</option>
<option value="14" label="Technologists, Technicians & Other Technical Services">Technologists, Technicians & Other Technical Services</option>
</select>
<span class="text-danger ng-hide" ng-show="pEvaluationForm.requester.Profession.$invalid">Select a Job Category</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.requester.Specialty.$invalid }">
<label class="control-label" for="specialty">Profession</label>
<select class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="Specialty"
ng-change="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Sub_Specialty__c = null; getSubspecialties(editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Discipline__c, editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Specialty__c)"
ng-model="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Specialty__c" ng-options="name for name in specialties[editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Discipline__c]" required="required">
<option value="0" label="Certified Medication Aide">Certified Medication Aide</option>
<option value="1" label="Certified Nurse Assistant">Certified Nurse Assistant</option>
<option value="2" label="Healthcare Professional">Healthcare Professional</option>
<option value="3" label="LPN/LVN">LPN/LVN</option>
<option value="4" label="Licensed Psychiatric Technician">Licensed Psychiatric Technician</option>
<option value="5" label="Medical Assistant">Medical Assistant</option>
<option value="6" label="Nursing Assistant">Nursing Assistant</option>
<option value="7" selected="selected" label="Registered Nurse">Registered Nurse</option>
</select>
<span class="text-danger ng-hide" ng-show="pEvaluationForm.requester.Specialty.$invalid">Select a Profession</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.requester.Subspecialty.$invalid }" ng-show="!editEvaluationInfo.IsNonClinician">
<label class="control-label" for="Subspecialty">Specialty</label>
<select class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="Subspecialty" ng-model="editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Sub_Specialty__c"
ng-options="name for name in subSpecialties[editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Discipline__c][editEvaluationInfo.WorkHistory.SkillSet__r.TRMNG__Specialty__c]" ng-required="!editEvaluationInfo.IsNonClinician"
required="required">
<option value="0" label="Addiction (Substance Use Disorder)">Addiction (Substance Use Disorder)</option>
<option value="1" label="Administrator">Administrator</option>
<option value="2" label="Ambulatory Care">Ambulatory Care</option>
<option value="3" label="Ambulatory OR">Ambulatory OR</option>
<option value="4" label="Ambulatory PACU">Ambulatory PACU</option>
<option value="5" label="Ambulatory Pre-Post Op">Ambulatory Pre-Post Op</option>
<option value="6" label="Antepartum">Antepartum</option>
<option value="7" label="Cardiac Rehabilitation">Cardiac Rehabilitation</option>
<option value="8" label="Cardiovascular Intensive Care">Cardiovascular Intensive Care</option>
<option value="9" label="Cardiovascular Operating Room">Cardiovascular Operating Room</option>
<option value="10" label="Case Management/Utilization Review">Case Management/Utilization Review</option>
<option value="11" label="Cath Lab">Cath Lab</option>
<option value="12" label="Chief Nursing Officer">Chief Nursing Officer</option>
<option value="13" label="Clinical Education Specialist">Clinical Education Specialist</option>
<option value="14" label="Clinical Research">Clinical Research</option>
<option value="15" label="College Health">College Health</option>
<option value="16" label="Community Health">Community Health</option>
<option value="17" label="Continence Care">Continence Care</option>
<option value="18" label="Continuing Education/Staff Development">Continuing Education/Staff Development</option>
<option value="19" label="Corrections">Corrections</option>
<option value="20" label="Critical Access">Critical Access</option>
<option value="21" label="Diabetes Educator">Diabetes Educator</option>
<option value="22" label="Dialysis">Dialysis</option>
<option value="23" label="Dialysis, Peritoneal">Dialysis, Peritoneal</option>
<option value="24" label="Director of Nursing">Director of Nursing</option>
<option value="25" label="Electrophysiology Lab">Electrophysiology Lab</option>
<option value="26" label="Emergency">Emergency</option>
<option value="27" label="Endoscopy">Endoscopy</option>
<option value="28" label="Enterostomal Therapy">Enterostomal Therapy</option>
<option value="29" label="Flight">Flight</option>
<option value="30" label="Gastroenterology">Gastroenterology</option>
<option value="31" label="General Practice">General Practice</option>
<option value="32" label="Gerontology">Gerontology</option>
<option value="33" label="Healthcare Professional">Healthcare Professional</option>
<option value="34" label="Hemodialysis">Hemodialysis</option>
<option value="35" label="Home Health">Home Health</option>
<option value="36" label="Home Health Pediatrics">Home Health Pediatrics</option>
<option value="37" label="Home Health Psych">Home Health Psych</option>
<option value="38" label="Home Infusion">Home Infusion</option>
<option value="39" label="Hospice">Hospice</option>
<option value="40" label="House Supervisor">House Supervisor</option>
<option value="41" label="ICU">ICU</option>
<option value="42" label="IV Therapy">IV Therapy</option>
<option value="43" label="Infection Prevention">Infection Prevention</option>
<option value="44" label="Informatics">Informatics</option>
<option value="45" label="Infusion Therapy">Infusion Therapy</option>
<option value="46" label="Interventional Radiology">Interventional Radiology</option>
<option value="47" label="Labor & Delivery">Labor & Delivery</option>
<option value="48" label="Lactation Consultant">Lactation Consultant</option>
<option value="49" label="Long Term Acute Care">Long Term Acute Care</option>
<option value="50" label="Maternal Newborn">Maternal Newborn</option>
<option value="51" label="Medical-Surgical">Medical-Surgical</option>
<option value="52" label="Neonatal Intensive Care - Level II">Neonatal Intensive Care - Level II</option>
<option value="53" label="Neonatal Intensive Care - Level III-IV">Neonatal Intensive Care - Level III-IV</option>
<option value="54" label="Neonatal, Low-Risk">Neonatal, Low-Risk</option>
<option value="55" label="Nephrology">Nephrology</option>
<option value="56" label="Neuroscience">Neuroscience</option>
<option value="57" label="Nurse Manager">Nurse Manager</option>
<option value="58" label="Nurse Massage Therapist (NMT)">Nurse Massage Therapist (NMT)</option>
<option value="59" label="Nutrition Support">Nutrition Support</option>
<option value="60" label="Obstetric, High-Risk">Obstetric, High-Risk</option>
<option value="61" label="Obstetric, Inpatient">Obstetric, Inpatient</option>
<option value="62" label="Occupational Health">Occupational Health</option>
<option value="63" label="Oncology">Oncology</option>
<option value="64" label="Operating Room">Operating Room</option>
<option value="65" label="Ophthalmic">Ophthalmic</option>
<option value="66" label="Orthopedic">Orthopedic</option>
<option value="67" label="Ostomy Care">Ostomy Care</option>
<option value="68" label="Otorhinolaryngology & Head-Neck">Otorhinolaryngology & Head-Neck</option>
<option value="69" label="Outpatient Clinic">Outpatient Clinic</option>
<option value="70" label="Outpatient Oncology">Outpatient Oncology</option>
<option value="71" label="PCU">PCU</option>
<option value="72" label="Pain Management">Pain Management</option>
<option value="73" label="Pedi Outpatient Clinic">Pedi Outpatient Clinic</option>
<option value="74" label="Pediatric Cardiovascular Operating Room">Pediatric Cardiovascular Operating Room</option>
<option value="75" label="Pediatric Emergency Room">Pediatric Emergency Room</option>
<option value="76" label="Pediatric Hematology-Oncology">Pediatric Hematology-Oncology</option>
<option value="77" label="Pediatric Intensive Care">Pediatric Intensive Care</option>
<option value="78" label="Pediatric Oncology">Pediatric Oncology</option>
<option value="79" label="Pediatric Operating Room">Pediatric Operating Room</option>
<option value="80" label="Pediatric Post Anesthesia Care">Pediatric Post Anesthesia Care</option>
<option value="81" label="Pediatric Rehabilitation/Long Term Acute Care">Pediatric Rehabilitation/Long Term Acute Care</option>
<option value="82" label="Pediatric Stepdown">Pediatric Stepdown</option>
<option value="83" label="Pediatrics">Pediatrics</option>
<option value="84" label="Perinatal">Perinatal</option>
<option value="85" label="Plastic Surgery">Plastic Surgery</option>
<option value="86" label="Post Anesthesia Care">Post Anesthesia Care</option>
<option value="87" label="Psych/Mental Health">Psych/Mental Health</option>
<option value="88" label="Psych/Mental Health, Adult">Psych/Mental Health, Adult</option>
<option value="89" label="Psych/Mental Health, Child & Adolescent">Psych/Mental Health, Child & Adolescent</option>
<option value="90" label="Registered Nurse First Assistant">Registered Nurse First Assistant</option>
<option value="91" label="Rehabilitation">Rehabilitation</option>
<option value="92" label="Reproductive Endocrinology/Infertility">Reproductive Endocrinology/Infertility</option>
<option value="93" label="Risk Management">Risk Management</option>
<option value="94" label="School">School</option>
<option value="95" label="Skilled Nursing">Skilled Nursing</option>
<option value="96" selected="selected" label="Telemetry">Telemetry</option>
<option value="97" label="Telephone Triage/Call Center">Telephone Triage/Call Center</option>
<option value="98" label="Urgent Care">Urgent Care</option>
<option value="99" label="Urology">Urology</option>
<option value="100" label="Women's Health Care, Ambulatory">Women's Health Care, Ambulatory</option>
<option value="101" label="Wound Care">Wound Care</option>
</select>
<span class="text-danger ng-hide" ng-show="pEvaluationForm.requester.Subspecialty.$invalid">Select a Specialty</span>
</div>
</div>
<div class="clearfix"></div>
<div class="btn-group pull-right">
<button class="btn btn-default btn-sm m-sm" ng-click="cancelEditingEvaluationInfo('requester')" type="button">Cancel</button>
<button class="btn btn-primary btn-sm m-sm" ng-click="updateEvaluationInfo(pEvaluationForm.requester.$valid,'requester')" type="button">Update</button>
</div>
</div>
</ng-form>
</div>
<div class="ibox-heading">
<h4>Your Profile<span class="pull-right"><a class="text-muted editLnk" onclick="$('#label-evaluator').hide(); $('#edit-evaluator').show();"><i class="fa fa-pencil-square-o "></i> Edit</a></span></h4>
</div>
<div class="ibox-content">
<div class="row" id="label-evaluator">
<div class="col-md-6">
<label>Name:</label>
<span ng-bind-html="editEvaluationInfo.Reference.TRMNG__First_Name__c" class="ng-binding">Meghan</span> <span ng-bind-html="editEvaluationInfo.Reference.TRMNG__Last_Name__c" class="ng-binding">Hess</span>
<br>
<label for="email">Email Address: </label>
<span ng-bind-html="editEvaluationInfo.Reference.TRMNG__Email__c" class="ng-binding">meghan.hess@uvmhealth.org</span>
<br>
<label for="position">Position Title: </label>
<span ng-bind-html="editEvaluationInfo.Reference.Title__c" class="ng-binding">Nurse Manager</span>
</div>
<div class="col-md-6">
<label for="Phone">Phone #: </label>
<span ng-bind-html="editEvaluationInfo.Reference.TRMNG__Phone__c" class="ng-binding">(802) 847-7742</span>
<br>
<label for="SecondaryPhone">Secondary Phone #: </label>
<span ng-bind-html="editEvaluationInfo.Reference.TRMNG__Secondary_Phone__c" class="ng-binding"></span>
</div>
</div>
<ng-form name="evaluator" class="ng-pristine ng-valid ng-valid-required">
<div class="row" id="edit-evaluator" style="display:none;">
<div class="col-md-6">
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.evaluator.EvalFirstName.$invalid }">
<label class="control-label" for="EvalFirstName">First Name</label>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="EvalFirstName" ng-model="editEvaluationInfo.Reference.TRMNG__First_Name__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.evaluator.EvalFirstName.$invalid">Please enter a First Name</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.evaluator.EvalLastName.$invalid }">
<label class="control-label" for="EvalLastName">Last Name</label>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="EvalLastName" ng-model="editEvaluationInfo.Reference.TRMNG__Last_Name__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.evaluator.EvalLastName.$invalid">Please enter a Last Name</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.evaluator.Position.$invalid }">
<label class="control-label" for="Position">Position Title</label>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="Position" ng-model="editEvaluationInfo.Reference.Title__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.evaluator.Position.$invalid">Please enter your Position Title</span>
</div>
</div>
<div class="col-md-6">
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.evaluator.Email.$invalid }">
<label class="control-label" for="Email">Email Address</label><br>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="Email" ng-model="editEvaluationInfo.Reference.TRMNG__Email__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.evaluator.Email.$invalid ">Please enter an Email</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.evaluator.PrimaryPhone.$invalid }">
<label class="control-label" for="PrimaryPhone">Phone #</label>
<input class="form-control ng-pristine ng-untouched ng-valid" name="PrimaryPhone" ng-model="editEvaluationInfo.Reference.TRMNG__Phone__c" type="text" ui-mask="(999) 999-9999" ui-mask-use-viewvalue="true" placeholder="(___) ___-____">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.evaluator.PrimaryPhone.$invalid ">Please enter a Primary Phone</span>
</div>
<div class="form-group">
<label for="eval_phone2">Secondary Phone #</label>
<input class="form-control ng-pristine ng-untouched ng-valid" name="SecondaryPhone" ng-model="editEvaluationInfo.Reference.TRMNG__Secondary_Phone__c" type="text" ui-mask="(999) 999-9999" ui-mask-use-viewvalue="true"
placeholder="(___) ___-____">
</div>
</div>
<div class="clearfix"></div>
<div class="btn-group pull-right">
<button class="btn btn-default btn-sm m-sm" ng-click="cancelEditingEvaluationInfo('evaluator')" type="button">Cancel</button>
<button class="btn btn-primary btn-sm m-sm" ng-click="updateEvaluationInfo(pEvaluationForm.evaluator.$valid,'evaluator')" type="button">Update</button>
</div>
</div>
</ng-form>
</div>
<div class="ibox-heading">
<h4>Facility/Employer <span class="pull-right"><a class="text-muted editLnk" onclick="$('#label-facility').hide(); $('#edit-facility').show();"><i class="fa fa-pencil-square-o "></i> Edit</a></span></h4>
</div>
<div class="ibox-content">
<div class="row" id="label-facility">
<div class="col-md-6 ng-binding">
<div>
<label>Name:</label>
<span ng-bind-html="editEvaluationInfo.WorkHistory.TRMNG__EmployerOrgName__c" class="ng-binding">TLC Nursing</span>
</div>
<label for="location">Location: </label>
<span ng-bind-html="editEvaluationInfo.WorkHistory.TRMNG__City__c" class="ng-binding">South Burlington</span>, VT 05401
</div>
<div class="col-md-46">
</div>
</div>
<ng-form name="facility" class="ng-pristine ng-valid ng-valid-required">
<div class="row" id="edit-facility" style="display:none">
<div class="col-md-6">
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.facility.EmployerOrgName.$invalid}">
<label class="control-label" for="EmployerOrgName">Name</label><br>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="EmployerOrgName" ng-model="editEvaluationInfo.WorkHistory.TRMNG__EmployerOrgName__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.facility.EmployerOrgName.$invalid">Please enter a Facility Name</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.facility.City.$invalid }">
<label class="control-label" for="City">City</label><br>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="City" ng-model="editEvaluationInfo.WorkHistory.TRMNG__City__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.facility.City.$invalid">Please enter a City</span>
</div>
</div>
<div class="col-md-6">
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.facility.State.$invalid}">
<label class="control-label" for="State">State/Province</label><br>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="State" ng-model="editEvaluationInfo.WorkHistory.TRMNG__StateProvince__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.facility.State.$invalid">Please enter a City</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.facility.ZipCode.$invalid }">
<label class="control-label" for="ZipCode">Zip</label><br>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="ZipCode" ng-model="editEvaluationInfo.WorkHistory.TRMNG__PostalCode__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.facility.ZipCode.$invalid">Please enter a ZipCode</span>
</div>
</div>
<div class="clearfix"></div>
<div class="btn-group pull-right">
<button class="btn btn-default btn-sm m-sm" ng-click="cancelEditingEvaluationInfo('facility')" type="button">Cancel</button>
<button class="btn btn-primary btn-sm m-sm" ng-click="updateEvaluationInfo(pEvaluationForm.facility.$valid,'facility')" type="button">Update</button>
</div>
</div>
</ng-form>
</div>
<div class="ibox-heading">
<h4>
<span ng-show="editEvaluationInfo.IsClinician">Unit Profile</span>
<span ng-show="editEvaluationInfo.IsNonClinician" class="ng-hide">Work Setting/Department</span>
<span class="pull-right"><a class="text-muted editLnk" onclick="$('#label-unit').hide(); $('#edit-unit').show();"><i class="fa fa-pencil-square-o "></i> Edit</a></span>
</h4>
</div>
<div class="ibox-content">
<div class="row" id="label-unit">
<div class="col-md-6">
<label for="unit" ng-show="editEvaluationInfo.IsClinician">Unit/Floor/Dept. name:</label>
<label for="unit" ng-show="editEvaluationInfo.IsNonClinician" class="ng-hide">Work Setting/Department:</label>
<span ng-bind-html="editEvaluationInfo.WorkHistory.Unit_Dept_Floor__c" class="ng-binding">Baird 6/Surgery</span> <br>
<label for="email">Position held/Job title:</label>
<span ng-bind-html="editEvaluationInfo.WorkHistory.TRMNG__Position_Title__c" class="ng-binding">Registered Nurse</span><br>
<label for="email" ng-show="editEvaluationInfo.IsClinician">Unit description: </label>
<label for="email" ng-show="editEvaluationInfo.IsNonClinician" class="ng-hide">Job Responsibilities:</label>
<span ng-bind-html="editEvaluationInfo.Reference.Unit_Description__c" class="ng-binding"></span>
<br>
</div>
<div class="col-md-6">
<div ng-show="editEvaluationInfo.IsClinician">
<label for="email">Number of beds in Unit:</label>
<span ng-bind-html="editEvaluationInfo.Reference.Unit_Number_of_Beds__c" class="ng-binding"></span><br>
<label for="email" ng-show="editEvaluationInfo.IsClinician"># of patients/shift: </label>
<span ng-bind-html="editEvaluationInfo.Reference.Average_Case_Load__c" class="ng-binding"></span>
</div>
<label for="email">Employed:</label> From <span ng-bind-html="editEvaluationInfo.WorkHistory.TRMNG__Start_Date__c | date : 'M/d/yy' " class="ng-binding">6/13/22</span>
<span ng-show="editEvaluationInfo.WorkHistory.TRMNG__End_Date__c != null"> to </span>
<span ng-bind-html="editEvaluationInfo.WorkHistory.TRMNG__End_Date__c | date : 'M/d/yy'" class="ng-binding">8/16/22</span><br>
</div>
</div>
<ng-form name="unit" class="ng-pristine ng-invalid ng-invalid-required">
<div class="row" id="edit-unit" style="display:none">
<div class="col-md-6">
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.unit.UnitDeptFloor.$invalid }">
<label class="control-label" ng-show="editEvaluationInfo.IsClinician">Unit/Floor/Dept. name</label>
<label class="control-label ng-hide" ng-show="editEvaluationInfo.IsNonClinician">Work Setting/Department</label>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="UnitDeptFloor" ng-model="editEvaluationInfo.WorkHistory.Unit_Dept_Floor__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.unit.UnitDeptFloor.$invalid ">This Field is required</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.unit.PositionHeld.$invalid }">
<label class="control-label" for="PositionHeld">Position held/Job title</label><br>
<input class="form-control ng-pristine ng-untouched ng-valid ng-valid-required" name="PositionHeld" ng-model="editEvaluationInfo.WorkHistory.TRMNG__Position_Title__c" required="required" type="text">
<span class="text-danger ng-hide" ng-show="pEvaluationForm.unit.PositionHeld.$invalid ">This Field is required</span>
</div>
<div class="form-group required has-error" ng-class="{ 'has-error' : pEvaluationForm.unit.CaseLoad.$invalid}" ng-show="editEvaluationInfo.IsClinician">
<label class="control-label"># of patients/shift</label>
<select class="form-control ng-pristine ng-untouched ng-invalid ng-invalid-required" name="CaseLoad" ng-model="editEvaluationInfo.Reference.Average_Case_Load__c" ng-required="editEvaluationInfo.IsClinician" required="required">
<option value="? undefined:undefined ?"></option>
<option value="n/a">n/a</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
</select>
<span class="text-danger" ng-show="pEvaluationForm.unit.CaseLoad.$invalid ">Please enter # of patients/shift</span> If not applicable, please select n/a.
</div>
</div>
<div class="col-md-6">
<div class="form-group required has-error" ng-class="{ 'has-error' : pEvaluationForm.unit.NoBeds.$invalid }" ng-show="editEvaluationInfo.IsClinician">
<label class="control-label" for="NoBeds">Number of beds in Unit</label><br>
<input class="form-control ng-pristine ng-untouched ng-invalid ng-invalid-required" name="NoBeds" ng-model="editEvaluationInfo.Reference.Unit_Number_of_Beds__c" ng-required="editEvaluationInfo.IsClinician" type="number"
required="required">
<span class="text-danger" ng-show="pEvaluationForm.unit.NoBeds.$invalid ">This Field is required</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.unit.EmployedFrom.$invalid }">
<label class="control-label">Dates Employed From</label>
<!-- ngIf: dateSupported --><input class="form-control ng-pristine ng-untouched ng-valid ng-scope ng-valid-required" name="EmployedFrom" ng-if="dateSupported" ng-model="editEvaluationInfo.WorkHistory.TRMNG__Start_Date__c"
required="required" type="date"><!-- end ngIf: dateSupported -->
<!-- ngIf: !dateSupported -->
<span class="text-danger ng-hide" ng-show="pEvaluationForm.unit.EmployedFrom.$invalid ">Please enter Employed Start Date</span>
</div>
<div class="form-group required" ng-class="{ 'has-error' : pEvaluationForm.unit.EmployedTo.$invalid }">
<label class="control-label">Dates Employed To</label>
<!-- ngIf: dateSupported --><input class="form-control ng-pristine ng-untouched ng-valid ng-scope" name="EmployedTo" ng-if="dateSupported" ng-model="editEvaluationInfo.WorkHistory.TRMNG__End_Date__c"
type="date"><!-- end ngIf: dateSupported -->
<!-- ngIf: !dateSupported -->
<span class="text-danger ng-hide" ng-show="pEvaluationForm.unit.EmployedTo.$invalid ">Please enter Employed End Date</span> (To date not required if currently working)
</div>
</div>
<div class="col-md-12">
<div class="form-group required has-error" ng-class="{ 'has-error' : pEvaluationForm.unit.UnitDescription.$invalid }">
<label class="control-label" ng-show="editEvaluationInfo.IsClinician">Unit description</label>
<label class="control-label ng-hide" ng-show="editEvaluationInfo.IsNonClinician">Job Responsibilities</label>
<br>
<input class="form-control ng-pristine ng-untouched ng-invalid ng-invalid-required" name="UnitDescription" ng-model="editEvaluationInfo.Reference.Unit_Description__c" required="required" type="text">
<span class="text-danger" ng-show="pEvaluationForm.unit.UnitDescription.$invalid ">Please enter a Unit Description</span> May include common patient diagnoses, patient acuity, special equipment used, special skills/competencies, etc.
</div>
</div>
<div class="clearfix"></div>
<div class="btn-group pull-right">
<button class="btn btn-default btn-sm m-sm" ng-click="cancelEditingEvaluationInfo('unit')" type="button">Cancel</button>
<button class="btn btn-primary btn-sm m-sm" ng-click="updateEvaluationInfo(pEvaluationForm.unit.$valid,'unit')" type="button">Update</button>
</div>
</div>
</ng-form>
</div>
<div class="ibox-heading">
<h4>Professional Reference</h4>
</div>
<div class="ibox-content">
<div class="row">
<h5> <strong>KEY: A = Superior B = Exceeds Standards C = Meets Standards D = Does Not Meet Standards </strong> </h5>
</div>
<div class="form-group required">
<table class="table table-striped" id="evalautor-ratings">
<tbody>
<tr>
<th class="col-sm-8"></th>
<th class="col-sm-4">
<table class="col-sm-12 m-l-xs">
<tbody>
<tr>
<th class="col-sm-3">A</th>
<th class="col-sm-3">B</th>
<th class="col-sm-3">C</th>
<th class="col-sm-3">D</th>
</tr>
</tbody>
</table>
</th>
</tr>
<!-- ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Effective_Communication__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Effective Communication</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Effective_Communication__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Effective_Communication__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Effective_Communication__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Effective_Communication__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Effective_Communication__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Ethical_Behavior__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Ethical Behavior</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Ethical_Behavior__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Ethical_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Ethical_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Ethical_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Ethical_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Initiative__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Initiative</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Initiative__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Initiative__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Initiative__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Initiative__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Initiative__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Adaptability__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Adaptability</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Adaptability__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Adaptability__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Adaptability__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Adaptability__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Adaptability__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Knowledge_and_Skills__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Competency - Knowledge/Skills</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Knowledge_and_Skills__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Knowledge_and_Skills__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Knowledge_and_Skills__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Knowledge_and_Skills__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Knowledge_and_Skills__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Patient_Family_Centered_Care__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Patient & Family Centered Care</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Patient_Family_Centered_Care__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Patient_Family_Centered_Care__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Patient_Family_Centered_Care__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Patient_Family_Centered_Care__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Patient_Family_Centered_Care__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Quality_of_Work__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Quality of Work</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Quality_of_Work__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Quality_of_Work__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Quality_of_Work__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Quality_of_Work__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Quality_of_Work__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Teamwork__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Teamwork & Cooperation</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Teamwork__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Teamwork__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Teamwork__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Teamwork__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Teamwork__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Documentation__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Accurate Documentation</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Documentation__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Documentation__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Documentation__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Documentation__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Documentation__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Reliability__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Reliability & Attendance</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Reliability__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Reliability__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Reliability__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Reliability__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Reliability__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
<tr ng-repeat="evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName" class="ng-scope">
<td ng-class="{ 'has-error' : pEvaluationForm.EvalQ_Professional_Behavior__c.$invalid && submittedPEvaluationInfo }">
<label class="control-label required ng-binding" ng-bind-html="evaluation.Question">Professional Behavior & Appearance</label>
<div class="text-danger pull-right ng-hide" ng-show="pEvaluationForm.EvalQ_Professional_Behavior__c.$invalid && submittedPEvaluationInfo"> A rating is required</div>
</td>
<td>
<table class="col-sm-12 m-t-sm">
<tbody>
<tr>
<td class="col-xs-3"><label><input name="EvalQ_Professional_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="A" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Professional_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="B" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Professional_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="C" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
<td class="col-xs-3"><label><input name="EvalQ_Professional_Behavior__c" ng-model="evaluation.Answer" required="required" type="radio" value="D" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl"></span></label></td>
</tr>
</tbody>
</table>
</td>
</tr><!-- end ngRepeat: evaluation in editEvaluationInfo.Evaluation.Questions track by evaluation.ColName -->
</tbody>
</table>
</div>
<div class="row m-b-sm">
<div class="form-group required has-error" id="ageLevel" ng-class="{ 'has-error' : competenciesSelected <= 0}" ng-show="editEvaluationInfo.ShowCompetencies">
<label class="control-label required">Age Level Competency</label>
<div class="clearfix"></div>
<!-- ngRepeat: competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency -->
<div class="col-sm-4 ng-scope" ng-repeat="competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency">
<label><input name="LevelCompetency" ng-click="countCheck(competency)" ng-model="competency.Answer" ng-required="editEvaluationInfo.ShowCompetencies && competenciesSelected <= 0" type="checkbox"
class="ng-pristine ng-untouched ng-invalid ng-invalid-required" required="required"><span class="lbl ng-binding">Infants</span></label>
</div><!-- end ngRepeat: competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency -->
<div class="col-sm-4 ng-scope" ng-repeat="competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency">
<label><input name="LevelCompetency" ng-click="countCheck(competency)" ng-model="competency.Answer" ng-required="editEvaluationInfo.ShowCompetencies && competenciesSelected <= 0" type="checkbox"
class="ng-pristine ng-untouched ng-invalid ng-invalid-required" required="required"><span class="lbl ng-binding">Children</span></label>
</div><!-- end ngRepeat: competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency -->
<div class="col-sm-4 ng-scope" ng-repeat="competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency">
<label><input name="LevelCompetency" ng-click="countCheck(competency)" ng-model="competency.Answer" ng-required="editEvaluationInfo.ShowCompetencies && competenciesSelected <= 0" type="checkbox"
class="ng-pristine ng-untouched ng-invalid ng-invalid-required" required="required"><span class="lbl ng-binding">Adolescents</span></label>
</div><!-- end ngRepeat: competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency -->
<div class="col-sm-4 ng-scope" ng-repeat="competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency">
<label><input name="LevelCompetency" ng-click="countCheck(competency)" ng-model="competency.Answer" ng-required="editEvaluationInfo.ShowCompetencies && competenciesSelected <= 0" type="checkbox"
class="ng-pristine ng-untouched ng-invalid ng-invalid-required" required="required"><span class="lbl ng-binding">Adults</span></label>
</div><!-- end ngRepeat: competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency -->
<div class="col-sm-4 ng-scope" ng-repeat="competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency">
<label><input name="LevelCompetency" ng-click="countCheck(competency)" ng-model="competency.Answer" ng-required="editEvaluationInfo.ShowCompetencies && competenciesSelected <= 0" type="checkbox"
class="ng-pristine ng-untouched ng-invalid ng-invalid-required" required="required"><span class="lbl ng-binding">Geriatrics</span></label>
</div><!-- end ngRepeat: competency in editEvaluationInfo.Evaluation.Competencies track by competency.Competency -->
<div class="clearfix"></div>
<span class="text-danger ng-hide" ng-show="competenciesSelected <= 0 && submittedPEvaluationInfo">At least one competency is required</span>
</div>
</div>
<div class="row m-b-sm">
<div class="form-group col-md-6 ng-hide" id="additional-free-text" ng-show="editEvaluationInfo.Evaluation.AdditionalQuestionType == 'FreeText'">
<label class="control-label"><span ng-bind-html="editEvaluationInfo.Reference.Eval_Additional_Question__c" class="ng-binding">Does RN interpret own telemetry strips?</span></label>
<input class="form-control ng-pristine ng-untouched ng-valid" name="AddFreeTextAnswer" ng-model="editEvaluationInfo.Reference.Eval_Additional_Answer__c" type="text">
</div>
<div class="form-group" id="additional-radio" ng-show="editEvaluationInfo.Evaluation.AdditionalQuestionType == 'RadioButton'">
<label class="control-label"> <span ng-bind-html="editEvaluationInfo.Reference.Eval_Additional_Question__c" class="ng-binding">Does RN interpret own telemetry strips?</span> </label> <br>
<label><input name="AddRadioAnswer" ng-model="editEvaluationInfo.Reference.Eval_Additional_Answer__c" type="radio" value="true" class="ng-pristine ng-untouched ng-valid"><span class="lbl">Yes</span></label>
<label><input name="AddRadioAnswer" ng-model="editEvaluationInfo.Reference.Eval_Additional_Answer__c" type="radio" value="false" class="ng-pristine ng-untouched ng-valid"><span class="lbl">No</span></label>
</div>
<div class="form-group ng-hide" id="additional-checkbox" ng-show="editEvaluationInfo.Evaluation.AdditionalQuestionType == 'CheckBox'">
<label class="control-label required"><span ng-bind-html="editEvaluationInfo.Reference.Eval_Additional_Question__c" class="ng-binding">Does RN interpret own telemetry strips?</span></label> <br>
<div class="col-sm-4">
<label><input id="answer-i" name="AddCheckBoxAnswer" ng-click="saveAdditionalCheckAnswer()" type="checkbox"><span class="lbl">I</span></label>
<label><input id="answer-ii" name="AddCheckBoxAnswer" ng-click="saveAdditionalCheckAnswer()" type="checkbox"><span class="lbl">II</span></label>
<label><input id="answer-iii" name="AddCheckBoxAnswer" ng-click="saveAdditionalCheckAnswer()" type="checkbox"><span class="lbl">III</span></label>
<label><input id="answer-iv" name="AddCheckBoxAnswer" ng-click="saveAdditionalCheckAnswer()" type="checkbox"><span class="lbl">IV</span></label>
<label><input id="answer-v" name="AddCheckBoxAnswer" ng-click="saveAdditionalCheckAnswer()" type="checkbox"><span class="lbl">V</span></label>
</div>
</div>
</div>
<div class="row m-b-sm">
<div class="form-group required" id="hire" ng-class="{ 'has-error' : pEvaluationForm.ReHire.$invalid && submittedPEvaluationInfo}">
<label class="control-label"> If you had the opportunity, would you rehire the candidate for a similar position? </label> <br>
<label><input name="ReHire" ng-model="editEvaluationInfo.Reference.Eval_Eligible_For_Hire__c" required="required" type="radio" value="true" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl">Yes</span></label>
<label><input name="ReHire" ng-model="editEvaluationInfo.Reference.Eval_Eligible_For_Hire__c" required="required" type="radio" value="false" class="ng-pristine ng-untouched ng-invalid ng-invalid-required"><span
class="lbl">No</span></label>
<span class="text-danger ng-hide" ng-show="pEvaluationForm.ReHire.$invalid && submittedPEvaluationInfo">This field is required</span>
</div>
<div class="col-md-6 form-group ng-hide" id="comments" ng-class="{ 'has-error' : pEvaluationForm.NoHireComments.$invalid && submittedPEvaluationInfo}" ng-show="editEvaluationInfo.Reference.Eval_Eligible_For_Hire__c == 'false'">
<label class="control-label">Please explain</label>
<textarea cols="82" name="NoHireComments" ng-model="editEvaluationInfo.Reference.Eval_No_Hire_Comment__c" ng-required="editEvaluationInfo.Reference.Eval_Eligible_For_Hire__c == 'false'"
class="ng-pristine ng-untouched ng-valid ng-binding ng-valid-required"></textarea>
<span class="text-danger ng-hide" ng-show="pEvaluationForm.NoHireComments.$invalid && submittedPEvaluationInfo">This field is required</span>
</div>
</div>
<div class="row">
<div class="col-md-6 form-group" id="comments">
<label class="control-label required">Please include any additional comments about the healthcare professional</label> <br><textarea cols="82" name="comments" ng-model="editEvaluationInfo.Reference.Eval_Additional_Comments__c"
class="ng-pristine ng-untouched ng-valid ng-binding"></textarea>
</div>
</div>
<div class="row">
<div class="btn-group pull-right">
<button class="btn btn-primary btn-sm m-sm " type="submit">Submit</button>
</div>
</div>
</div>
</div><!-- end ngIf: editEvaluationInfo.IsReferenceInProgress -->
<!-- ngIf: editEvaluationInfo.IsReferenceReceived -->
<!-- ngIf: !editEvaluationInfo.IsReferenceReceived && !editEvaluationInfo.IsReferenceInProgress -->
</div>
</form>Text Content
REFERENCE REQUEST The individual named below has applied for employment with one of the AMN Healthcare brands and has named you as a reference contact. Please complete all required fields and submit the form by clicking on the submit button. Your response will be held in the strictest confidence. REQUESTOR PROFILE EDIT Name: Lora Campbell-East Email: fullerlora5@gmail.com Job Category: Nursing Profession: Registered Nurse Specialty: Telemetry First Name Please enter a First Name Last Name Please enter a Last Name Email fullerlora5@gmail.com Job Category Behavioral Health & Social ServicesChiropractic ProvidersDental ProvidersDietary & Nutrition ServicesEmergency Medical Service ProvidersEye and Vision Services ProvidersNursingNursing SupportPharmacyPhysician Assistants & Advanced Practice Nursing ProvidersPodiatric Medicine & Surgery Service ProvidersRehabilitation & Respiratory ServicesSpeech, Language & Hearing ServicesStudent, Health CareTechnologists, Technicians & Other Technical Services Select a Job Category Profession Certified Medication AideCertified Nurse AssistantHealthcare ProfessionalLPN/LVNLicensed Psychiatric TechnicianMedical AssistantNursing AssistantRegistered Nurse Select a Profession Specialty Addiction (Substance Use Disorder)AdministratorAmbulatory CareAmbulatory ORAmbulatory PACUAmbulatory Pre-Post OpAntepartumCardiac RehabilitationCardiovascular Intensive CareCardiovascular Operating RoomCase Management/Utilization ReviewCath LabChief Nursing OfficerClinical Education SpecialistClinical ResearchCollege HealthCommunity HealthContinence CareContinuing Education/Staff DevelopmentCorrectionsCritical AccessDiabetes EducatorDialysisDialysis, PeritonealDirector of NursingElectrophysiology LabEmergencyEndoscopyEnterostomal TherapyFlightGastroenterologyGeneral PracticeGerontologyHealthcare ProfessionalHemodialysisHome HealthHome Health PediatricsHome Health PsychHome InfusionHospiceHouse SupervisorICUIV TherapyInfection PreventionInformaticsInfusion TherapyInterventional RadiologyLabor & DeliveryLactation ConsultantLong Term Acute CareMaternal NewbornMedical-SurgicalNeonatal Intensive Care - Level IINeonatal Intensive Care - Level III-IVNeonatal, Low-RiskNephrologyNeuroscienceNurse ManagerNurse Massage Therapist (NMT)Nutrition SupportObstetric, High-RiskObstetric, InpatientOccupational HealthOncologyOperating RoomOphthalmicOrthopedicOstomy CareOtorhinolaryngology & Head-NeckOutpatient ClinicOutpatient OncologyPCUPain ManagementPedi Outpatient ClinicPediatric Cardiovascular Operating RoomPediatric Emergency RoomPediatric Hematology-OncologyPediatric Intensive CarePediatric OncologyPediatric Operating RoomPediatric Post Anesthesia CarePediatric Rehabilitation/Long Term Acute CarePediatric StepdownPediatricsPerinatalPlastic SurgeryPost Anesthesia CarePsych/Mental HealthPsych/Mental Health, AdultPsych/Mental Health, Child & AdolescentRegistered Nurse First AssistantRehabilitationReproductive Endocrinology/InfertilityRisk ManagementSchoolSkilled NursingTelemetryTelephone Triage/Call CenterUrgent CareUrologyWomen's Health Care, AmbulatoryWound Care Select a Specialty Cancel Update YOUR PROFILE EDIT Name: Meghan Hess Email Address: meghan.hess@uvmhealth.org Position Title: Nurse Manager Phone #: (802) 847-7742 Secondary Phone #: First Name Please enter a First Name Last Name Please enter a Last Name Position Title Please enter your Position Title Email Address Please enter an Email Phone # Please enter a Primary Phone Secondary Phone # Cancel Update FACILITY/EMPLOYER EDIT Name: TLC Nursing Location: South Burlington, VT 05401 Name Please enter a Facility Name City Please enter a City State/Province Please enter a City Zip Please enter a ZipCode Cancel Update UNIT PROFILE WORK SETTING/DEPARTMENT EDIT Unit/Floor/Dept. name: Work Setting/Department: Baird 6/Surgery Position held/Job title: Registered Nurse Unit description: Job Responsibilities: Number of beds in Unit: # of patients/shift: Employed: From 6/13/22 to 8/16/22 Unit/Floor/Dept. name Work Setting/Department This Field is required Position held/Job title This Field is required # of patients/shift n/a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Please enter # of patients/shift If not applicable, please select n/a. Number of beds in Unit This Field is required Dates Employed From Please enter Employed Start Date Dates Employed To Please enter Employed End Date (To date not required if currently working) Unit description Job Responsibilities Please enter a Unit Description May include common patient diagnoses, patient acuity, special equipment used, special skills/competencies, etc. Cancel Update PROFESSIONAL REFERENCE KEY: A = SUPERIOR B = EXCEEDS STANDARDS C = MEETS STANDARDS D = DOES NOT MEET STANDARDS A B C D Effective Communication A rating is required Ethical Behavior A rating is required Initiative A rating is required Adaptability A rating is required Competency - Knowledge/Skills A rating is required Patient & Family Centered Care A rating is required Quality of Work A rating is required Teamwork & Cooperation A rating is required Accurate Documentation A rating is required Reliability & Attendance A rating is required Professional Behavior & Appearance A rating is required Age Level Competency Infants Children Adolescents Adults Geriatrics At least one competency is required Does RN interpret own telemetry strips? Does RN interpret own telemetry strips? Yes No Does RN interpret own telemetry strips? I II III IV V If you had the opportunity, would you rehire the candidate for a similar position? Yes No This field is required Please explain This field is required Please include any additional comments about the healthcare professional Submit × ATTESTATION I attest that I am the evaluator named on this form and that the information provided is complete and accurate to the best of my knowledge. Close Submit Follow Us Nursefinders is a full-service nurse and allied staffing agency, offering the widest selection of per diem nurse and allied health jobs in the industry. 2023 AMN Healthcare, Inc. All rights reserved. Reproduction and distribution of these materials is prohibited without the expressed written authorization of AMN Healthcare, Inc.