Employee Performance Evaluation Form

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EMPLOYEE PERFORMANCE EVALUATION
E
N
:
MPLOYEE
AME
(F
, MI,
)
IRST
LAST
J
T
:
OB
ITLE
D
:
EPARTMENT
P
E
:
From:
To:
ERIOD OF
VALUATION
T
:
Initial 3-Month
Annual
Interim
YPE OF EVALUATION
_____________________________________________________________________________
PART I – INSTRUCTIONS TO EVALUATOR
Listed below are sections for the performance evaluation of job duties, adherence to agency
policies and supervisory factors that are important in the performance of the employee’s job.
Performance of job duties and adherence to agency policies must be evaluated for all employees.
The supervisor factors should be utilized only for employees with supervisory responsibilities. The
“overall performance” evaluation should reflect the employee’s total performance, including the
performance of job duties and adherence to agency policy.
NOTE: Objective comments which provide specific feedback on job performance benefit the
employee. Evaluators are encouraged to provide specific, objective comments which support
each rating. A rating of either Needs Improvement or Exceeds Expectations requires
objective comments in support of the rating.
1.
Return the original form to Human Resources,
D
ISTRIBUTION
2.
Maintain one copy for your records
I
NSTRUCTIONS
Provide a copy to the employee
3.
RATING SCALE:
The following rating scale guide is to be used by the evaluator in assigning the most appropriate
measurement of the employees’ job duties, adherence to agency policy, and, if applicable,
performance of supervisory factors.
1. Needs Improvement – Performance and/or adherence to policy must
improve to meet expectations of the position
2. Meets Expectations – Competently performs job duties; requires no
more guidance, training or supervision than is typically required of people
in this position
3. Exceeds expectations – Frequently performs at a level higher than the
performance standard; accomplishments were made in areas other than
the stated job duties
EMPLOYEE PERFORMANCE EVALUATION
E
N
:
MPLOYEE
AME
(F
, MI,
)
IRST
LAST
J
T
:
OB
ITLE
D
:
EPARTMENT
P
E
:
From:
To:
ERIOD OF
VALUATION
T
:
Initial 3-Month
Annual
Interim
YPE OF EVALUATION
_____________________________________________________________________________
PART I – INSTRUCTIONS TO EVALUATOR
Listed below are sections for the performance evaluation of job duties, adherence to agency
policies and supervisory factors that are important in the performance of the employee’s job.
Performance of job duties and adherence to agency policies must be evaluated for all employees.
The supervisor factors should be utilized only for employees with supervisory responsibilities. The
“overall performance” evaluation should reflect the employee’s total performance, including the
performance of job duties and adherence to agency policy.
NOTE: Objective comments which provide specific feedback on job performance benefit the
employee. Evaluators are encouraged to provide specific, objective comments which support
each rating. A rating of either Needs Improvement or Exceeds Expectations requires
objective comments in support of the rating.
1.
Return the original form to Human Resources,
D
ISTRIBUTION
2.
Maintain one copy for your records
I
NSTRUCTIONS
Provide a copy to the employee
3.
RATING SCALE:
The following rating scale guide is to be used by the evaluator in assigning the most appropriate
measurement of the employees’ job duties, adherence to agency policy, and, if applicable,
performance of supervisory factors.
1. Needs Improvement – Performance and/or adherence to policy must
improve to meet expectations of the position
2. Meets Expectations – Competently performs job duties; requires no
more guidance, training or supervision than is typically required of people
in this position
3. Exceeds expectations – Frequently performs at a level higher than the
performance standard; accomplishments were made in areas other than
the stated job duties
PART II – PERFORMANCE OF JOB DUTIES & COMPETENCIES
(The
Supervisor should choose 5 job duties & 3 competencies from the employee’s job
description to evaluate)
1. Job Duty –
Performance Standard:
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
2. Job Duty –
Performance Standard:
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
3. Job Duty –
Performance Standard:
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
4. Job Duty –
Performance Standard:
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
5. Job Duty –
Performance Standard:
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
6. Competency-
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
7. Competency-
Page 2 of 6
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
8. Competency-
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
Page 3 of 6
PART III - ADHERENCE TO POLICY
1. Attendance – Attends work regularly and is punctual. Personal time off and other leave is
approved rather than unplanned.
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
2. Fosters a Positive Work Environment – Treats co-workers, clients, suppliers, vendors,
members of the public, and management with courtesy and respect; willingly completes
assigned work and readily assists others in the performance of their duties.
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
3. Respects Diversity – Treats clients and co-workers with dignity and does not discriminate
against or harass clients or co-workers because of disability, race, color, gender, age, religion,
ethnicity, citizenship status, sexual orientation, or sexual identity. Promptly reports use of
inappropriate jokes, comments and racial, ethnic, gender or other slurs to management.
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
4. Maintains Confidentiality –Follows HIPPA requirements as applicable to job duties;
Maintains client confidentiality, only sharing information with those with a medical need to
know. Maintains confidentiality of employee and donor information, as applicable to job duties.
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
Page 4 of 6
PART IV - SUPERVISORY FACTORS
1. Leadership –Demonstrates effective supervisory abilities; gains respect and cooperation;
inspires and motivates subordinates; directs work group toward common goal; achieves
departmental goals in furtherance of the mission and agency objectives.
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
2. Delegation –Effectively directs others in accomplishing work; effectively selects and
motivates staff; defines assignments; oversees the work of subordinates
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
3. Planning and Organizing –Plans and organizes work; coordinates work with others to
ensure timely completion of assignments; establishes appropriate priorities; anticipates future
needs and acts to meet those needs; carries out assignments effectively.
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
4. Administration – Performs day-to-day administrative tasks; manages time effectively;
administers policies uniformly and equitably; implements procedures; maintains appropriate
contact with supervisor and effectively and appropriately utilize funds, staff and equipment
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
5. Human Resources Management – Models appropriate behavior in support of the mission for
employees; provides guidance and opportunities to staff for their development and
advancement; promptly and effectively resolves work-related employee issues, concerns and
deficiencies; assists subordinates in accomplishing their work-related objectives;
communicates well with subordinates in a clear, concise, accurate, and timely manner; and
makes useful suggestions.
1 Needs Improvement
2 Meets Expectations
3 Exceeds Expectations
Comments:
Page 5 of 6

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