State Form 19959 - Employee Performance Appraisal Report - Supervisory And Managerial
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1Employee name:____________________________________________
EMPLOYEE PERFORMANCE
TYPE OF EVALUATION
SUPERVISORY
APPRAISAL REPORT
Annual
3-Month
6-Month
Follow-up
AND MANAGERIAL
State Form 19959 (R7 / 2-00)
Other:
*Social Security number request is mandatory
per IC 4-1-8-1 (5)
WORKING TEST
This information may be used in decisions
Successfully completed: Permanent status granted. EFFECTIVE DATE:
concerning training needs, advancement,
performance-related salary adjustments,
Request extension for six (6) months. Reason on Comments Sheet. EXTENDED DUE DATE:
layoffs, reemployment, and as evidence in
contested disciplinary actions.
State Personnel Director approval
Date (month, day, year)
*Social Security number
Name of employee
Name of state agency
Org code
Class title and class code of employee
Review period (month / year)
To
AREAS OF RESPONSIBILITY
QUALITY
IMP.
QUANTITY
TIMELINESS
INSTRUCTIONS
RESPONSIBILITY STATEMENT
Na
Es Ne
=
Na
=
=
Na
=
=
1.
1) List the applicable areas of responsibility
from the position description. 2) Indicate the
2.
relative importance of each in the second column.
3.
3) Assign a rating to each dimension based on
4.
the actual work performed. Substantiate ratings of
"below standard" on Comments Sheet.
5.
:
key
Essential
Non-Essential
Es
Ne
6.
Not applicable
Below standard
Na
7.
At standard
Above standard
=
8.
GENERAL FACTORS
IMPORT.
PERFORMANCE
INSTRUCTIONS
FACTOR
Es
Ne
U
Na
M
S
V
0
1. Planning and Organizing
1) Indicate the relative importance of each
factor in the first column. 2) For each applicable
2. Directing and Coordinating
factor, assign the most suitable performance
3. Staffing/Affirmative Action
rating. Substantiate ratings of "Unsatisfactory"
or "Outstanding" on Comments Sheet.
4. Employee performance Appraisal
Key:
Essential
Non-Essential
Ne
Es
5. Employee Relations
Not applicable
Unsatisfactory
U
Na
6. Public Relations
Marginal
Satisfactory
S
M
7. Budgeting
Very good
Outstanding
O
V
8. Job Knowledge and Expertise
Evaluator signature
Superior
Appointing Authority signature
Employee signature
Date signed
Date
I hereby certify that I have had an opportunity to review this report and
I hereby certify that this rating report constitutes my best judgment of the service performed by this employee for the review period
understand that I am to receive a copy. I am aware that my signature
covered.
does not necessarily mean that I agree with the rating.
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Parent category: Legal