Employee name:____________________________________________
EMPLOYEE PERFORMANCE
TYPE OF EVALUATION
PROFESSIONAL
APPRAISAL REPORT
ADMINISTRATIVE and
Annual
3-Month
6-Month
Follow-up
TECHNOLOGICIAL
State Form 19958 (R5 /2-99)
Other:
*Social Security number request is mandatory
per IC 4-1-8-1 (5)
WORKING TEST (Merit Agencies Only)
This information may be used in decisions
Successfully completed: Permanent status granted. EFFECTIVE DATE:
concerning training needs, advancement,
Request extension for six (6) months. Reason on Comments Sheet. EXTENDED DUE DATE:
performance-related salary adjustments,
layoffs, reemployment, and as evidence in
State Personnel Director approval
Date (month, day, year)
contested disciplinary actions.
*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
FACTOR
Es
Ne
U
INSTRUCTIONS
Na
M
S
V
0
1. Job Knowledge and Skill
1) Indicate the relative importance of each
factor in the first column. 2) For each applicable
2. Communication Functions
factor, assign the most suitable performance
3. Work Coordination
rating. Substantiate ratings of "Unsatisfactory"
or "Outstanding" on Comments Sheet.
4. Dependability
Key:
Ne
Essential
Non-essential
Es
5. Problem-solving
U
Not applicable
Unsatisfactory
Na
6. Financial Planning
S
Marginal
Satisfactory
M
7. Supervisory Functions
O
Very good
Outstanding
V
8. Interpersonal Relations
Evaluator signature
Superior
Appointing Authority signature
Date
Employee signature
Date signed
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.
1
