State Form 19954 - Employee Performance Appraisal Report - Clerical

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Employee name:____________________________________________
EMPLOYEE PERFORMANCE
TYPE OF EVALUATION
CLERICAL
APPRAISAL REPORT
Annual
3-Month
6-Month
Follow-up
State Form 19954 (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
IMP.
QUALITY
TIMELINESS
QUANTITY
RESPONSIBILITY STATEMENT
INSTRUCTIONS
Na
Es Ne
=
Na
=
Na
=
1) List the applicable areas of responsibility
1.
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
the actual work performed. Substantiate ratings of
4.
"below standard" on Comments Sheet.
5.
:
key
Es
Essential
Ne
Non-Essential
6.
Na
Not applicable
Below standard
7.
At standard
Above standard
=
8.
GENERAL FACTORS
IMPORT.
PERFORMANCE
FACTOR
Es
INSTRUCTIONS
Ne
Na
U
M
S
0
V
1. Job Knowledge and Skill
1) Indicate the relative importance of each
factor in the first column. 2) For each applicable
2. Communication
factor, assign the most suitable performance
3. Work Planning
rating. Substantiate ratings of "Unsatisfactory"
or "Outstanding" on Comments Sheet.
4. Flexibility
Key:
Ne
Essential
Non-essential
Es
5. Independence
U
Not applicable
Unsatisfactory
Na
6. Judgement / Following Procedures
S
Marginal
Satisfactory
M
7. Work Commitment
O
Very good
Outstanding
V
8. Interpersonal Relations
Employee signature
Date signed
Evaluator signature
Superior
Appointing Authority signature
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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