Performance Evaluation Appeal Form (Page 2 of 2) in pdf

AGENCY APPEALS BOARD SUMMARY STATEMENT

The following statement summarizes the basis for our recommended decision:

(Attach additional sheets, if necessary)

AGENCY HEAD DECISION

I have reviewed the recommendation of the Agency Board. Your appeal is:

Sustained

Denied

Signed __________________________________________________________

Date Issued

Agency Head or Designee

STEP 2 - STATEWIDE LEVEL

Instructions

If your appeal has been denied at the agency level, you have 15 calendar days from the date you receive the agency level decision to

appeal to the Statewide Performance Evaluation Appeals Board. To do so, complete this form in the space provided below. Attach

legible copies of your performance program and evaluation forms, worksheets, and any other pertinent documents. Employees must

send these documents by Certified Mail - Return Receipt Requested to the Statewide Performance Evaluation Appeals Board, c/o

Governor's Office of Employee Relations, 2 Empire State Plaza, Suite 1201, Albany, NY 12223-1250.

You must provide reasons for your disagreement with the agency level decision, and sign and date the form where indicated.

You must also send a copy of this Appeals Form to your Agency Personnel Office.

Employees (with the exception of Management/Confidential employees) are entitled to appear before the Statewide Appeals Board to

explain their reasons for disagreement with the agency level decision. If you wish to do so 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.

Reasons for Disagreement with STEP 1 - AGENCY LEVEL decision: _____________________________________________________

____________________________________________________________________________________________________________

(Attach additional sheets, if necessary)

I request a personal appearance before the Statewide Appeals Board (PS&T, ASU, ISU, OSU, DMNA and RRSU only).

Employee’ s Signature _________________________________________________ Date Submitted__________________________

Mailing Address ______________________________________________________________________________________________

Street

City

State

Zip Code

Home Telephone (__________) __________________________ Work Telephone (___________) __________________________

Area Code

STATEWIDE APPEALS BOARD DECISION

Date Request Received by Statewide Appeals Board _________________________________________________________

Your appeal has been reviewed by the Statewide Appeals Board. We have:

9 Sustained

9 Denied

your appeal.

As a result of this action, your rating for this evaluation period is

Signed __________________________________________________________

Date

DDS(1/97)

Performance Evaluation Appeal Form Page 2

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