SAMPLEN ONLY - May not be current evaluation
INDEPENDENCE
Exempt Employee Evaluation Form
Cover Page/Signatures
Employee Name: ___________________________________________
Employee Number: ____________________
Evaluator Name: ___________________________________________
Evaluation Period:
From: ______________________ To: ______________________
Type of Evaluation:
____ Annual
____ Probationary
____ Other
Employee Comments:
Signatures:
___________________________________________________
Employee
Date
Signature does not indicate agreement but indicates that the evaluation has been reviewed with
the employee.
___________________________________________________
Evaluator
Date
___________________________________________________
Department Director
Date
Exempt Employee Performance Evaluation - Part I - Page 1