HR0901 (11/12)
Health and Human Services System
Performance Evaluation
Type of Evaluation (place an x after your choice) tab to next cell
End of probation:
Annual:
Transfer:
Special:
tab to next cell
Hire Date:
Next Review Date:
Reporting period tab to next cell
from:
to:
Identifying Information tab to next cell
Employee Name:
Employee ID:
Salary Group:
Functional Title:
Classification Title:
Classification Number:
Job Description tab to next cell
Tasks and Standards
tab to next cell
Instructions and Rating Scale tab to next cell
Rate each task using the following scale and the established performance standard(s). A professional development plan
must be developed for each task rated below 3 and is encouraged when the overall rating is 3, to identify and improve
areas of weakness, and 4 or 5, to promote career opportunities.
1 = Performance needs major improvement
Performance generally does not meet the standard(s) established for the task.
2 = Performance needs some improvement
Performance generally meets part, but not all, of the standard(s) established for the task.
3 = Performance is competent
Performance consistently meets and sometimes exceeds the standard(s) established for the task.
4 = Performance is commendable
Performance routinely surpasses the standard(s) established for the task.
5 = Performance is distinguished
Performance so consistently and dramatically surpasses the standard(s) established for the task
that the employee's expertise is broadly recognized outside the employee's own area. tab to next
cell
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HR0901 (11/12)
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
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HR0901 (11/12)
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
next cell
Page 3 of 14
HR0901 (11/12)
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
Page 4 of 14
HR0901 (11/12)
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
next cell
Page 5 of 14
HR0901 (11/12)
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
Page 6 of 14
HR0901 (11/12)
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
next cell
Page 7 of 14
HR0901 (11/12)
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
Page 8 of 14
HR0901 (11/12)
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Task:
Performance Standard(s):
Evaluation Comments:
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
next cell
Page 9 of 14
HR0901 (11/12)
Performance Dimensions tab to next cell
Instructions and Rating Scale tab to next cell
Rate each dimension using the following scale. A rating of 1 or 2 must be justified in the Supervisor’s Comments section.
1 = Performance needs major improvement
Performance generally does not meet the standard(s) established for the performance
measures for the dimension.
2 = Performance needs some improvement
Performance generally meets part, but not all, of the standard(s) established for the
performance measures for the dimension.
3 = Performance is competent
Performance consistently meets and sometimes exceeds the standard(s) established for the
performance measures for the dimension.
4 = Performance is commendable
Performance routinely surpasses the standard(s) established for the performance measures
for the dimension.
5 = Performance is distinguished
Performance so consistently and dramatically surpasses the standard(s) established for the
performance measures for the dimension that the employee is broadly recognized outside
the employee's own area. tab to next cell
Initiative - Below are examples of some, but certainly not all performance measures that may be associated with this
dimension. Employees excelling in these or other appropriate measures for this dimension would be rated Distinguished.

Willingly assumes new and challenging assignments.

Seeks challenging goals for self.

Willingly puts in extra time and effort in crisis situations.

Expends the effort and time necessary to do the job well.

Routinely shows an interest in improving his/her knowledge and skill level.

Offers suggestions to solve problems or improve operations.

Takes action to achieve goals beyond what is required. tab to next cell
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Planning and Organization - Below are examples of some, but certainly not all performance measures that may be
associated with this dimension. Employees excelling in these or other appropriate measures for this dimension would be
rated Distinguished.

Participates in identifying goals in group settings.

Identifies and coordinates resources.

Manages projects and tasks in an effective, accountable, and responsible manner.

Develops plans while considering all relevant factors, including work group, clients, program goals, agency goals,
and needs of community. tab to next cell
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Decision-Making - Below are examples of some, but certainly not all performance measures that may be associated with
this dimension. Employees excelling in these or other appropriate measures for this dimension would be rated
Distinguished.

Identifies and considers all feasible alternatives before making decisions.

Can make decisions on limited but adequate information.

Uses a mix of analysis, wisdom, experience and judgment.

Initiates proactive approach to identifying needs and solving problems. tab to next cell
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HR0901 (11/12)
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Flexibility and Adaptability - Below are examples of some, but certainly not all performance measures that may be
associated with this dimension. Employees excelling in these or other appropriate measures for this dimension would be
rated Distinguished.

Effectively handles multiple responsibilities.

Embraces changing conditions and situations in work responsibilities.

Accepts constructive criticism and suggestions and uses them to improve performance.

Deals with anger, frustration and disappointment in a professional manner.

Maintains objectivity in all situations.

Seeks solutions acceptable to all.

Fits approach to the task, situation, problem, or person.

Responds promptly and effectively to requests for information. tab to next cell
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Communication and Interpersonal Skills - Below are examples of some, but certainly not all performance measures
that may be associated with this dimension. Employees excelling in these or other appropriate measures for this
dimension would be rated Distinguished.

Demonstrates clear, concise, effective verbal and written communications skills.

Uses content (words, level of detail) appropriate for audience.

Keeps all agency records, information and client's names confidential.

Keeps supervisor and co-workers informed of work activities.

Builds constructive and effective relationships.

Interacts with people at all levels in the organization in a positive manner.

Actively and attentively listens.

Exhibits leadership qualities. tab to next cell
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Professionalism - Below are examples of some, but certainly not all performance measures that may be associated with
this dimension. Employees excelling in these or other appropriate measures for this dimension would be rated
Distinguished.

Considers agency’s mission statement, values and vision in making decisions and taking actions.

Maintains state and agency standards of conduct.

Attends work regularly in accordance with agency policies and procedures.

Displays professional attitude, actions and work attire.

Promotes and demonstrates appropriate respect for cultural diversity among co-workers and all work-related
contacts. tab to next cell
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Page 11 of 14
HR0901 (11/12)
Supervisory and Human Resources Responsibilities (supervisory staff only) - Below are examples of some, but
certainly not all performance measures that may be associated with this dimension. Employees excelling in these or other
appropriate measures for this dimension would be rated Distinguished.

Provides effective supervision of assigned staff.

Provides information, guidance, and development opportunities for assigned staff.

Ensures that assigned staff participate in mandatory training.

Provides ongoing, effective and useful performance feedback.

Prepares appraisals that accurately reflect employee achievements and abilities.

Completes and shares appraisals in a timely manner.

Handles personnel/performance problems in accordance with agency policies and expectations.

Delegates responsibility with commensurate amount of authority and follows up effectively.

Effectively involves assigned staff in decisions affecting them, unit and division.

Promotes and advocates principles of workforce diversity.

Demonstrates ability to identify and utilize agency resources, policies and procedures for management related
issues. tab to next cell
Rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Acknowledgment of Performance Plan
I acknowledge that a copy of this performance plan has been shared with me on this date.
Employee Signature:
Date:
First-line Supervisor Signature:
Date:
Second-line Supervisor Signature (optional):
Date:
Overall Performance Rating
Overall
performance
rating: (place
an x after 1, 2,
3, 4, or 5) tab to
1. Needs major
improvement:
2. Needs some
improvement:
3. Competent:
4. Commendable:
5. Distinguished:
next cell
Supervisor’s Comments:
Recommendation:
Change to Regular Status
Retain at Regular Status
Other (specify):
Professional Development Plan there are 5 sets of objective fields; tab to next cell
Objective – strategy for improvement:
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HR0901 (11/12)
Responsible person – employee, supervisor, or other person:
Completion date – expected or actual:
Objective – strategy for improvement:
Responsible person – employee, supervisor, or other person:
Completion date – expected or actual:
Objective – strategy for improvement:
Responsible person – employee, supervisor, or other person:
Completion date – expected or actual:
Objective – strategy for improvement:
Responsible person – employee, supervisor, or other person:
Completion date – expected or actual:
Objective – strategy for improvement:
Responsible person – employee, supervisor, or other person:
Completion date – expected or actual:
License Verification (for positions requiring licenses)
Is license current and valid?
Yes:
No:
If Yes, give the date that validity was verified:
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HR0901 (11/12)
Acknowledgment of Performance Evaluation tab to next cell
I have received, read, and discussed this evaluation with my supervisor. I understand that my signature here does not
mean that I agree with this evaluation and I understand that I may respond to this evaluation in writing. Note: If the
employee wishes to comment on the performance evaluation, the employee should submit the written comments to the
supervisor within five workdays of receipt of the evaluation. tab to next cell
Employee Signature:
Date:
I have discussed this evaluation with the employee and have given the employee a copy. Note: The supervisor attaches
the employee comments, if any, to the original performance evaluation. tab to next cell
First-line Supervisor Signature:
Date:
Second-line Supervisor’s Review (Optional) tab to next cell
Second-line Supervisor Signature:
Date:
This is the end of form HHSSHR501. Press CTRL + HOME to return to the top of the form.
This is the end of the Form form.
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