Hygienist 90-Day Review

Employee Information

Hygienist Name

Home Office

Current Hourly Rate ($)

Current Tier

Hire Date

Review Date

Reviewer (OM Name)

Review Period

Rating Scale · 1 Does Not Meet · 2 Partially Meets · 3 Meets Expectations · 4 Exceeds · 5 Outstanding

Part I — KPI Performance

/ 25 pts

KPI	Target	Actual	Score (1–5)

Part I Total: 0 / 25

KPI Notes — Data Sources, Context, Exceptions

Part II — 90-Day Performance Evaluation

/ 30 pts (6 categories × 5)

Category	Score (1–5)

Part II Total: 0 / 30

Performance Notes

Part I — KPIs

0 / 25

Part II — Performance

0 / 30

Combined Score

0 / 55

Fill in scores above

—

out of 55 points

Feedback & Development

Strengths Observed

Areas for Improvement

90-Day Goals & Action Plan

Employee Response / Comments

Tier Competency Checklist

Gate A · Gate B

Mark each skill: ✓ Can do or ✗ Cannot do. Leave blank if not yet evaluated. Gate A = all skills at current tier and below are ✓. Gate B = all skills at next tier are also ✓ (required to promote).

Gate A — Current Tier Mastery

Select your tier above

Required for advancement

Gate B — Next Tier Mastery

Select your tier above

Required for promotion

Overall Assessment & Recommendation

Recommendation

Continue as Planned

Employee is meeting expectations. Continue standard onboarding and development path.

Extend Probationary Period

Additional time and coaching needed before full confirmation. Set clear milestones.

Recommend Rate Adjustment

Employee has exceeded 90-day expectations. Rate adjustment recommended — process through standard approval.

Release / Separation

Employee is not meeting minimum expectations. Coordinate with HR before proceeding.

I certify this employee is ready to advance to the next tier

Check only if Gate B is passed and advancement is agreed upon.

Overall Comments

Signatures & Submission

Employee

Employee Signature (typed name)

Date

Office Manager

OM Signature (typed name)

Date

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