Created: 04/09/2001 Page 1 of 7

YCS PERFORMANCE EVALUATION FORM

Revised: 4/01/2014 Vice President of Treatment Homes

EMPLOYEE NAME: ______FACILITY/PROGRAM (specify): ______

REVIEWER NAME: ______REVIEWER TITLE: ______

EVALUATION PERIOD: 90 Day Annual Job Change ………..TIME FRAME OF EVAL: From ______To ______

The age of the clients served: ___ under 1 year; ___ 1-4 yrs; ___ 5-12 yrs; ___13-17 yrs; ___ 18-22 yrs ; ____ 23+ yrs ____ n/a

/ SOURCE
OF DATA*
(abbreviation) / RATING** / COMMENTS
(If necessary, attach additional sheets) /
DUTIES AND RESPONSIBILITIES
2.1.1  Ensures compliance with the policies and procedures of Youth Consultation Service.
2.1.2 Oversees the recruitment, orientation, training and support of families and homes.
2.1.3 Responsible for program budgets, resources, and staffing protocols.
2.1.4 Oversees the internal home studies, questionnaires and life safety inspections and coordinates all Division of Child Protection and Permanency (DCPP) reviews.
2.1.5 Performs random life safety inspections to ensure compliance with standards.
2.1.6 In collaboration with the Marketing VP, perform any necessary marketing and/or public relations function(s).
2.1.7 Upholds and maintains the quality of service provided by the program.
2.1.8 Participates in agency-wide meetings, Cabinet; serves on any Agency committees.
2.1.9 Conducts audits on consumer and family files to ensure compliance with all applicable standards.
2.1.10 Provides leadership, coordination and support to recruitment staff.
2.1.11 Develops yearly program goals and objectives geared at program enhancements.
2.1.12 Performs additional responsibilities as directed by the President /CEO.
2.2.1  Supervises and evaluates Treatment Home staff.
2.2.2  Oversees grievances, disciplinary action, evaluations, raise pool determinations, promotions and terminations.
2.2.3 In coordination with Recruitment Coordinator, coordinates staff development by ensuring completion of training required by licensing agency and core competency training.
2.3.1 Participates in agency-wide meetings, Cabinet; serve on any community committees.
2.3.2 Develops yearly program goals and objectives geared at program enhancements.
2.3.3  Ensures that agency mission statement is reflected in all long range, strategic and operational plans, resource allocation and organizational policies.
2.4.1 Demonstrates empathy and compassion in conduct towards clients/families.
2.4.2 Demonstrates respect, cooperation, consideration and tact in dealing with subordinates, peers, supervisors and others.
2.5 Cooperates with the licensee and the applicable State department or division licensing unit with any legally mandated inspections or investigations.
GOAL(S)
Accomplished assigned goal(s) for the preceding year.
CORE COMPETENCY TRAINING
Core competency trainings completed
(If 100% of core competency trainings are completed, the score is 4
If any of the core competencies are not completed, the score is 1
There are no scores of 2 or 3 for this item)
CORE VALUES (All Staff)
ATTENDENCE & PUNCTUALITY
Regularly present and punctual
Calls supervisor in advance if unable to report to work
DEPENDABILITY/ FLEXIBILITY
Completes assignments on time and carries out instructions
Performs well under pressure and handles multiple assignments
Takes on new responsibilities
COMMUNICATION
Communicates knowledge clearly, accurately, and thoroughly
Listens attentively and responds thoughtfully
TEAMWORK
Coordinates own work with others, seeks opinions, values working relationships
SAFETY COMPLIANCE
Regularly attentive to safety and health regulations
RESPECTFUL EMPLOYEE RELATIONS
Treats all people with respect
Values diverse perspectives
Provides constructive feedback to staff
Maintains confidentiality of sensitive issues
CORE VALUES (Supervisory Staff Only)
CONFLICT RESOLUTION
Resolves conflicts quickly and fairly by implementing appropriate procedures which lead to positive outcomes
LEADERSHIP/ACCOUNTABILITY/OWNERSHIP
Takes personal responsibility for unit’s success and leads to achieve goals
Honest and ethical in all responsibilities entrusted to him/her.
STAFF DEVELOPMENT Fosters employee advancement Encourages individual and/or unit training and development of staff members Supports staff participation in committees and in-service training Respects aspirations of people within the department Takes personal responsibility for hiring decisions that support the advancement of women and multicultural community
AFFIRMATIVE ACTION & DIVERSITY SUPPORT
Participates in diversity training opportunities both for self and encourages staff Provides a supportive work environment for a multicultural workforce
BUDGETARY CONTROLS
Accurately forecasts and maintains budgetary projections; controls operating costs by effectively utilizing staff, materials, equipment
Project 1 (Description):
Add all of the scores in the “Rating Column.”
Count the number of items rated. Do not include items rated N for Not Applicable. Divide the sum of all the rated items by the number of items rated and place that number in the “Average Rating” space at the right. / The sum of all of the rated items =
______
The number of items rated =
______Average Rating =
______
GOAL FOR THE 20______- 20______YEAR (Required)
(If necessary, attach additional sheets)
SUPERVISOR COMMENTS (Optional)
(If necessary, attach additional sheets)
EMPLOYEE COMMENTS (Optional)
(If necessary, attach additional sheets)

OVERALL PERFORMANCE RATING Please check one:

Highly Effective (Average score of 3.55-4.0) Effective (Average score of 2.55-3.54)

Needs Improvement (Average score of 1.55.-2.54) Unsatisfactory (Average score of 1.0 to 1.54)

______

(I) Employee’s signature Date Administrator’s signature Date

______
(II) Employee’s signature
(This signature (II) confirms that my Supervisor has provided me with, and reviewed my job description with me prior to me signing this evaluation).

*SOURCES OF DATA MAY INCLUDE ONE OR MORE OF THE FOLLOWING (Use abbreviations):

Record Review (RR); Direct Observation (DO); Supervision (S); Case Conferences (CC);Client Feedback (CF); Auditor Feedback (AF); Staff Feedback (SF);

Personnel Record (PR).

SUMMARY OF PERFORMANCE (Attach additional sheets, if necessary)

Numerically rate whether the employee’s performance has exceeded, met or not met the performance standards. Be as specific and quantitative as possible. If the performance is numerically rated either: 1) Unsatisfactory or 2) Needs Improvement, please provide a written description of performance. For ratings of 3 and above, a numerical rating in the right hand column is sufficient.

**PERFORMANCE RATINGS: 1 = Unsatisfactory 2 = Needs Improvement 3 = Effective 4 = Highly Effective N = Not Applicable

PLEASE FORWARD COMPLETED EVALUTIONS TO THE HUMAN RESOURCES DEPARTMENT