Form CH-40 "Employee Performance Appraisal" - Kentucky

What Is Form CH-40?

This is a legal form that was released by the Kentucky Department for Public Health - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 1993;
  • The latest edition provided by the Kentucky Department for Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CH-40 by clicking the link below or browse more documents and templates provided by the Kentucky Department for Public Health.

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CH-40 April 1, 1993
EMPLOYEE PERFORMANCE APPRAISAL
LOCAL HEALTH DEPARTMENTS OF KENTUCKY
Part I
Employee’s Name – Last, First, Middle
Social Security Number
Position Title
Agency
Work Station
Period of Appraisal
Type of Appraisal
Date due
From:
To:
Annual
Other
Probationary
Instructions:
An evaluation must be completed at least annually on each employee and is required prior to completion of a Probationary Period or
the denial of an Annual Increment.
1. Complete all items in Part I
4. Discuss with employee in conference
2. Complete Parts II–IV
5. Allow employee review, comment and signature
3. Record overall evaluation in Part VII;
6. As appropriate, make changes and complete signatures
7. Place a copy in the employee’s file and send a copy to the Merit System Office
sign and date appropriately
(See Parts II–IV on the back)
Part V: Remarks by supervisor.
Give brief narrative of evaluation of employee. List recommendations and suggestion. Briefly state
performance GOALS for next evaluation period.
Part VI: (optional) Remarks by employee.
Indicate your work objectives and goals for the next evaluation period. You may comment in
this section or submit additional comments if you do not concur with evaluation.
Part VII: Overall Evaluation of Employee
Inadequate
Below
Meets
Exceeds
Outstanding
Requirements
Requirements
Requirements
Part VIII: Recommendation
Employee should receive increment
Employee should not receive increment
Employee should receive permanent
Employee should not receive permanent
status
status
Employee’s Signature:
I Concur
I Do Not Concur
I hereby certify that this rating has been
discussed with me by my supervisor
Supervisor’s Signature
Title
Date
Reviewer’s Signature
Title
Date
CH-40 April 1, 1993
EMPLOYEE PERFORMANCE APPRAISAL
LOCAL HEALTH DEPARTMENTS OF KENTUCKY
Part I
Employee’s Name – Last, First, Middle
Social Security Number
Position Title
Agency
Work Station
Period of Appraisal
Type of Appraisal
Date due
From:
To:
Annual
Other
Probationary
Instructions:
An evaluation must be completed at least annually on each employee and is required prior to completion of a Probationary Period or
the denial of an Annual Increment.
1. Complete all items in Part I
4. Discuss with employee in conference
2. Complete Parts II–IV
5. Allow employee review, comment and signature
3. Record overall evaluation in Part VII;
6. As appropriate, make changes and complete signatures
7. Place a copy in the employee’s file and send a copy to the Merit System Office
sign and date appropriately
(See Parts II–IV on the back)
Part V: Remarks by supervisor.
Give brief narrative of evaluation of employee. List recommendations and suggestion. Briefly state
performance GOALS for next evaluation period.
Part VI: (optional) Remarks by employee.
Indicate your work objectives and goals for the next evaluation period. You may comment in
this section or submit additional comments if you do not concur with evaluation.
Part VII: Overall Evaluation of Employee
Inadequate
Below
Meets
Exceeds
Outstanding
Requirements
Requirements
Requirements
Part VIII: Recommendation
Employee should receive increment
Employee should not receive increment
Employee should receive permanent
Employee should not receive permanent
status
status
Employee’s Signature:
I Concur
I Do Not Concur
I hereby certify that this rating has been
discussed with me by my supervisor
Supervisor’s Signature
Title
Date
Reviewer’s Signature
Title
Date
Employee’s Name
PERFORMANCE ELEMENTS
Part II:
TO BE COMPLETED ON ALL EMPLOYEES
1.
Completes work assignments ..............................................................................
2.
Does routine work without specific instructions ....................................................
3.
Remembers office or agency procedures and operates according to them ..........
4.
Meets deadlines when they exist .........................................................................
5.
Listens to and accepts instructions ......................................................................
6.
Shifts to new tasks when priorities change ..........................................................
7.
Does work accurately and quickly ........................................................................
8.
Checks work for accuracy ....................................................................................
9.
Files or keeps records accurately ........................................................................
10.
Is interested in and concerned about work ...........................................................
11.
Gets along with co-workers to accomplish job tasks ............................................
12.
Discusses assignments and problems with superior ............................................
13.
Deals tactfully with the public on the telephone or in person ................................
14.
Uses sick leave appropriately ..............................................................................
15.
Expresses ideas well in writing ............................................................................
16.
Expresses ideas well orally ..................................................................................
17.
Possesses the technical knowledge/skill to handle assignments .........................
18.
Is faithful and punctual in attendance ...................................................................
19.
Looks for opportunities to develop greater skills in the job ...................................
20.
Meets or exceeds expectations of quantity of work ..............................................
21.
Meets or exceeds quality of work demanded by program goals and objectives ....
22.
Approaches assignments in a positive manner ....................................................
23.
Exercises care in the use of equipment and supplies ...........................................
24.
Establishes priorities in work assignments in order to efficiently accomplish job
tasks
25.
Is willing to work overtime when job duties demand it ..........................................
Part III:
TO BE COMPLETED ONLY FOR EMPLOYEES WHO CURRENTLY HOLD SUPERVISORY POSITIONS
1.
Plans and organizes to accomplish work goals .....................................................
2.
Trains and instructs subordinates .........................................................................
3.
Evaluates subordinates objectively on the basis of work performance ..................
4.
Coordinates distribution of workloads for maximum efficiency ..............................
5.
Exercises appropriate management control to accomplish work ...........................
6.
Demonstrates leadership in problem solving, policy statements and procedural
recommendations .................................................................................................
7.
Exercises operational economy ............................................................................
8.
Exercises courtesy in dealing with employees, other superiors and the public ......
9.
Understands the value of team work and approaches problems with that
understanding ......................................................................................................
10.
Disciplines in a consistent and constructive manner .............................................
11.
Exercises innovative methods to solve problems ..................................................
12.
Analyzes the cause of problems effectively ..........................................................
13.
Possesses sound technical judgment as evidenced by effective solutions to work
problems .............................................................................................................
14.
Demonstrates administrative or managerial professionalism in handling of work,
people and issues ................................................................................................
15.
Exercises sufficient tenacity to accomplish work goals within the prescribed limits
of time and resources ...........................................................................................
Part IV:
NUMBER OF ELEMENTS CHECKED
Final rating is based upon overall evaluation with appropriate weight
given to the most significant performance elements.
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