Keystone Community Living, Inc
Employee Performance Appraisal
Employee Name: ______
Date of Hire: ______
Current Job Title: ______
Date evaluation assigned: ______
Status:
- Full Time
- Part Time
- Per Diem
- Exempt
- Non Exempt
Purpose of this performance review:
- Assess an employee’s performance during an appraisal period
- Help determine the employee’s suitability for continued employment
- Provide information for the promotion/transfer process
- Assist in the development of an employee’s career goals
- Satisfy a requirement of licensing
Instructions:
Employee evaluations are assigned to the employee near his/her anniversary date.
The Director of Human Resources assigns the evaluations.
The employee is expected to complete the “Employee Section” within 7-10 days of assignment.
He/she is then expected to pass the evaluation onto his/her immediate supervisor.
The supervisor is then expected to complete “The Immediate Supervisor’s” section and schedule a meeting with the employee within 7-10 days.
Together, the two will determine areas of concentration for the upcoming year and make recommendations.
Completed, signed evaluations are to be reviewed by the supervisor’s supervisor, and then returned to the Director of Human Resources.
The entire process, from assignment to completion should take no more than 30 days.
Employee’s Section (Please complete this section and return it to ______in 7-10 days from the above assignment date:
Which best describes your attendance/punctuality during this past year?
- Seldom late or absent (no more than 6 times)
- Occasionally late or absent (7-12 times)
- Often late or absent (13-24 times)
- Extreme tardiness/extended absence (more than 25 times)
Explain:
______
Which best describes your job performance during this past year?
(check all that apply)
- Received one or more positive recognitions
- Received no corrective actions
- Received one to three corrective actions
- Received four or more corrective actions
Explain:
______
Achievements: (List any achievements that you are most proud of accomplishing in your current position this past year.)
______
Opportunities:
List the areas in which you need to grow.
______
List the areas in which you might serve as a resource/talent to the individuals served or Keystone’soverall program.
______
Immediate Supervisor’s Section:
Did the employee meet the deadline of 7-10 days from assignment?
- Yes
- No
If no, explain:
______
Did the employee accurately assess his/her attendance/punctuality?
- Yes
- No
If no, explain:
______
Did the employee accurately assess his/her job performance?
- Yes
- No
If no, explain:
______
This section is to be completed by both employee and immediate supervisor in a face-to-face meeting. This face-to-face meeting occurred on ______:
Priorities: Together, establish two employee goals for the next year. Be sure these goals are measurable. (Next year, these goals will be revisited to determine success)
1. ______
2. ______
List any resources or tools needed to accomplish these goals:
______
Collective Recommendations (check all that apply):
- 1. Continue employment
- 2. Consider employee in future opportunities for transfer
- 3. Consider employee in future opportunities for promotion
- 4. Assist employee in getting more training (note specific area:______)
- 5. Employment deemed unsuccessful; re-evaluate in ______months
- 6. Termination of employment
Employee’s signature & date and if desired, further comment:
______Date: ______
Immediate Supervisor’s signature & date, and if desired, further comment:
______Date: ______
Supervisor’s Supervisor’s signature (After this has been signed by both the employee and his/her immediate supervisor, the supervisor should hand it to his/her supervisor for review and signature.)
______Date: ______
Comments if desired: ______
For Human Resources:
Date evaluation assigned: ______
Date evaluation returned: ______
Follow Up Required:
- No (if recommendations 1-3 are checked)
- Yes (if recommendations 4-6 are checked)
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