Worksite Monitor Report – Tennessee Medical Foundation

Participant Name*

First Last

Worksite Monitor*

First Last

Worksite Monitor Email Address*

Reporting Quarter*

To Be Completed by Work Site Monitor

How often have you had personal contact in the last three months?*

Please report any observed changes (positive or negative) in the individual's behavior:

I have observed changes in the individual's attendance.*

If yes, please explain:*

I have observed changes in the individual's personal habits.*

If yes, please explain:*

I have observed changes in the individual's practice performance.*

If yes, please explain:*

I have observed changes in the individual's interpersonal relationships.*

If yes, please explain:*

I have observed changes in the individual's social behavior.*

If yes, please explain:*

I have observed changes related to the individual's use of prescription and/or non-prescription drugs or alcohol.*

If yes, please explain:*

Did the individual face any significant professional/personal challenges this quarter?*

If yes, please explain:*

Is the individual's overall performance satisfactory?*

If no, please explain:*

Do you have any concerns about the individual's workplace performance?*

If yes, please explain:*

Any additional comments:

Would you like the TMF to contact you?*

Signature of Work Site Monitor:*

Date*

Security Code

Type the code you see above into the Security Code box for verification.

Comments

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