Form 0750 Sample - Performance Appraisal Program
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PERFORMANCE APPRAISAL PROGRAM
IMPORTANT: For additional information see VA Handbook 5013/1, Part 1. If additional space is needed for any item on this form, use page 6.
PERFORMANCE PLAN AND APPRAISAL OF
EMPLOYEE'S NAME (Last, First, Middle Initial)
POSITION TITLE, SERIES AND NUMBER
GRADE/SALARY
Joe Green
Administrative Support Assistant
GS-6
DEPARTMENT/OFFICE
LOCATION
DATE ASSIGNED PRESENT POSITION
DUE DATE OF WITHIN-GRADE INCREASE
PERIOD COVERED BY THIS PERFORMANCE PLAN
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
FROM
TO
SIGNATURE AND TITLE OF RATER PREPARING THIS
DATE
SIGNATURE OF EMPLOYEE
DATE
(MM/DD/YYYY)
(MM/DD/YYYY)
PERFORMANCE PLAN
SAMPLE
SECTION A - PERFORMANCE PLAN
Reflect the performance elements for the position to be rated. An element is defined as a component of a position that is sufficiently important to
warrant written appraisal. Normally each position has four or five elements. Designate with an asterisk the element(s) considered critical. Specific
performance standards must be written for each element. There are usually three to five performance standards for each element. When writing
performance standards, only the fully successful level of achievement need be defined.
PERFORMANCE ELEMENTS/STANDARDS
Non-Critical Element: Interpersonal Effectiveness
1.• P erformance Standard: Employee responds to veteran inquiries by providing a response
within 10 days of an inquiry. No more than “10” valid complains annually.
2.• P erformance Standard:
Written communications with veterans, peers, or supervisors will
clearly communicate the purpose so that “95”% of letters do not require content
correction or clarification.
3.• P erformance Standard: Communications, both oral and written, are provided in a prompt
manner as evidenced by random supervisory review of documents and quality monitoring in
“2”% of cases.
Critical Element: Correspondence Preparation
1.• P erformance Standard: No instances of inappropriate release of veteran medical
information.
2.• P erformance Standard: Employee will ensure that access to veteran or other electronic
information is not available to other employees.
Critical Element: Customer Service
1.• P erformance Standard: Consistently communicates with veterans in a courteous, tactful
and helpful manner with no more than “2” valid complaints annually.
2.• P erformance Standard: Routinely interacts in a professional and courteous manner with
employees and others outside the facility with no more than “5’ valid complaints.
VA FORM
AdobeFormsDesigner
0750
NOV 2003 (RS)
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