Performance Evaluation Appeal Form printable pdf download

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 Management/Confidential

9 Professional, Scientific and Technical Services

9 Administrative Service

9 Institutional Services

Rent Regulation Services

9 Operational Services

9 DMNA

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

Instructions

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

Signed __________________________________________________________

Date_________________________________

Performance Evaluation Appeal Form