State of New York
PERFORMANCE EVALUATION APPEALS FORM
This form is for use by Management/Confidential employees and employees in the following bargaining units who wish to
appeal a rating of “Unsatisfactory”: Professional, Scientific and Technical unit represented by PEF; Administrative Services,
Operational Services, Insitutional Services and Division of Military and Naval Affairs units represented by CSEA; and Rent
Regulation Services unit represented by DC-37.
Please print or type
Unit (check one):
9 Professional, Scientific and Technical Services
9 Administrative Service
9 Institutional Services
Rent Regulation Services
9 Operational Services
Your Name _____________________________________________________________________________________________
Agency ______________________________________ Facility/Division ____________________________________________
Item No. _____________________________________ Title______________________________________________________
Name of Supervisor ____________________________ Name of Reviewer _________________________________________
Date Rating Received __________________________ Evaluation Period: From _______________To ___________________
You may seek to have your "Unsatisfactory" rating raised to the next higher rating category and you have 15 calendar days from
the date you receive your rating to file an appeal. The first step will be a review of your appeal by your Agency Performance
Evaluation Appeals Board (STEP 1 below).
STEP 1 - AGENCY LEVEL
To appeal your "Unsatisfactory" rating, complete this form in the space provided below and submit it to your Agency Appeals Board.
# Unless you cite specific reasons why your work performance deserves a higher rating, your appeal will be dismissed. Only your
rating may be appealed. Disputes concerning such issues as your individual performance program and the rating and appeals
process are not subject to appeal.
# Employees who appeal their rating may make a personal appearance before their Agency Appeals Board to explain their reasons
for appeal. If you wish to make a personal appearance, you must indicate this by checking the box below.
# CSEA-, PEF- and DC-37-represented employees are entitled to be accompanied by a representative appointed by their respective
unions. M/C-designated employees may be accompanied by a person of their choosing who may act as an observer only.
Reasons for Appeal: ______________________________________________________________________________________
(Attach additional sheets, if necessary)
9 I request a personal appearance before the Agency Appeals Board
Employee's Signature ________________________________________________Date Submitted ________________________
AGENCY APPEALS BOARD RECOMMENDED DECISION
Date Request Received by Agency Appeals Board _________________________________________
The appeal of the above-named employee has been received and we recommend that the appeal be:
9 Sustained 9 Denied