State Form 52403 - Employee Work Profile And Performance Appraisal Report Page 6

If this form is being used as communication of the Work Profile, not a Performance Appraisal,

please sign on the appropriate line below.

____________________________________________________

_____________________

Signature of Employee

Date (month, day, year)

____________________________________________________

_____________________

Signature of Supervisor

Date (month, day, year)

If this form is being used as a Performance Appraisal, please sign on the appropriate line

below.

I hereby certify that this report constitutes an accurate evaluation using my best judgment of the service performed by this employee for the review period

covered.

Signature of Evaluator

Signature of Reviewer

Signature of Appointing Authority

Date (month, day, year)

I hereby certify that I have had an opportunity to review this report and understand that I am to receive a copy. I am aware that my signature does not

necessarily mean I agree with the rating.

Signature of Employee

Date (month, day, year)