PERFORMANCE EVALUATION
1= Unsatisfactory
2=Marginal
Rating
Score
1.0-1.50
Performance Key:
3=Meets Requirements
1.51-2.50
4=Exceeds Requirements
2.51-3.50
5=Exceptional
3.51-4.50
4.51-5.00
Company Name: Jerolin Management Services, LLC
Employee Performance Review – Long Format
Employee Information
Employee Name:
Job Title:
Department:
Employee ID:
Direct Support Professional
Date:
Residential Services
Superviser:
Overall Performance Score
Review Period:
Review Guidelines
PART I
At least one week prior to this review, notify employee of the review, and assign the employee a self-review as well as an
employee peer review.
All goals should be reasonable and specific. Documentation is required for performance ratings of 2 or less or for a performance
rating of 5.
After documenting your performance rating multiply that number by the percentage for that goal and write your score.
Once all goals have been scored total your scores for each outcome and enter the total in the Total Rating in the Calculation
section at the end of Part I and multiply by 75%. This will give you your final score for Part I.
Briefly describe the Performance of the employee for each category. Was the Performance achieved? If no, then why not?
Essential Function #1: Results Expected/Performance Standard Weight 20% x Rating
= Score
QUALITY MGMT/RECORDKEEPING
Demonstrate the ability to document effectively, monitor and review individual’s service record
Comply with all established legislation, mandated program standards, and Jerolin Management Services, LLC requirements regarding
consumer services and documentation of services.
Completes, submits and make corrections on monthly record reviews for all charts.
Was the Essential Function achieved? □ Yes □ No If no, then why not?
Essential Function #2: Results Expected/Performance Standard Weight 10% x Rating
= Score
SERVICES PROVISION:
Consistently exercise discretion and good judgment related to consumer services and crisis situations.
Performance Evaluation
Associate Coordinator
10.2013/revised 11.2015
Page 1 of 6
PERFORMANCE EVALUATION
1= Unsatisfactory
Rating
Score
1.0-1.50
2=Marginal
Performance Key:
3=Meets Requirements
1.51-2.50
4=Exceeds Requirements
2.51-3.50
5=Exceptional
3.51-4.50
4.51-5.00
Communicate with individuals with various sensory impairments, mental limitations and physical limitations.
Collaborate, communicate and participate in service coordination with case managers, programs, family members, and other agencies to
ensure appropriate and supportive services delivery.
Provide supervision and support to individuals in their program and ensure maintenance of health & safety. This also includes general
monitoring, monitoring during scheduled group meetings and educational trainings with individuals
Was the Essential Function achieved? ☐ Yes ☐ No If no, then why not?
Essential Function #3: Results Expected/Performance Standard Weight 15% x Rating
= Score
PLAN FOR SUPPORT:
Monitor individual’s desired outcomes, behavioral interventions, and progress and preference according to information identified on the
Individual’s Plan for Support.
Was the Essential Function achieved? ☐ Yes ☐ No If no, then why not?
Essential Function #4:Results Expected/Performance Standard Weight 20% x Rating
= Score
COMMITEES MEETINGS:
Attends and participates on committees and meetings for the purpose of information exchange, services coordination and quality
assurance.
Was the Essential Function achieved? ☐ Yes ☐ No If no, then why not?
Essential Function #5:Results Expected/Performance Standard Weight 10% x Rating
= Score
TRANSPORTATION ASSISTANCE:
Provide, arranges and supports Individuals to meet transportation needs.
Must be able to accompany Individuals in the program to various community activity locations and appointments, if applicable (ex:
Performance Evaluation
Associate Coordinator
10.2013/revised 11.2015
Page 2 of 6
PERFORMANCE EVALUATION
1= Unsatisfactory
Rating
Score
1.0-1.50
2=Marginal
1.51-2.50
Performance Key:
3=Meets Requirements
4=Exceeds Requirements
2.51-3.50
5=Exceptional
3.51-4.50
4.51-5.00
medical). Was the Essential Function achieved? ☐ Yes ☐ No If no, then why not?
Essential Function #6: Results Expected/Performance Standard Weight 5% x Rating
= Score
STAFF DEVELOPMENT:
Participate in all required training activities, seminars, and conferences to enhance skills and understanding of service delivery changes.
Participate in the following trainings prior to expiration of their date: Confidentiality/HIPPA, Human Rights, CPR/First Aid, Behavior
Management, and Universal Precautions. These training certifications last for 1 year with the exception of CRP/First Aid when last for
2 years.
Medication Training –one time upon hire and every 2 years refresher training, thereafter.
Participate in I.D. Waiver Provider and Documentation Trainings through the Department of Mental Health, Mental Retardation and
Substance Services, when offered.
Participate in company-sponsored trainings: ID and General documentation, upon hire and as needed document.
Was the Essential Function achieved? ☐ Yes ☐ No If no, then why not?
Essential Function #7:Results Expected/Performance StandardWeight10% x Rating
= Score
Was the Essential Function achieved? ☐ Yes ☐ No If no, then why not?
Essential Function #8:Results Expected/Performance Standard Weight 10 x Rating
= Score
REPORT SUBMISSIONS:
Completes and submits all programmatic, financial, audit reports and forms, while meeting identified deadlines.
Were the Essential Function achieved? ☐ Yes ☐ No If no, then why not?
PART I – CALULATIONS
Performance Evaluation
Associate Coordinator
10.2013/revised 11.2015
Page 3 of 6
PERFORMANCE EVALUATION
1= Unsatisfactory
Rating
Score
1.0-1.50
0
x
2=Marginal
1.51-2.50
TOTAL OF RATINGS PART I
Performance Key:
3=Meets Requirements
4=Exceeds Requirements
2.51-3.50
____75%______ =
ASSIGNED WEIGHT
3.51-4.50
5=Exceptional
4.51-5.00
0
PART I TOTAL SCORE
Review Guidelines
PART II
Use this rating key for the following evaluation:
1 = Unsatisfactory
Does not perform required tasks. Requires constant supervision
2 = Marginal
Needs improvement in quality of work. Completes tasks, but not on time.
3 = Meets Requirements
Meets basic requirements. Tasks are completed on time.
4 = Exceeds Requirements
Goes above and beyond expectations.
5 = Exceptional
Always gets results far beyond what is required.
Total the number of performance items for each column.
Then multiply each column’s total number of performance items in each column (A) by the key rating (B) for that
column. This will give you your Performance Rating for each column.
Total the Performance Rating for each column and enter the score in the Total Performance Rating section in Part II
in the Calculation section at the end of Part II and multiply by 25%. This will give you your final score for Part II.
There are 12 Performance Items
(5) =
Exceptional
(4) = Exceeds
Requirements
(3) = Meets
Requirements
(2) = Marginal
(1) =
Unsatisfactory
Achieves Set Objectives
Open To Constructive Criticism
Demonstrates Required Job
Skills And Knowledge
Demonstrates Effective
Management And Leadership
Skills
Completes All Assigned
Responsibilities
Meets Attendance
Requirements
Takes Responsibility For
Actions
Recognizes Potential Problems
Performance Evaluation
Associate Coordinator
10.2013/revised 11.2015
Page 4 of 6
PERFORMANCE EVALUATION
1= Unsatisfactory
Rating
Score
1.0-1.50
2=Marginal
Performance Key:
3=Meets Requirements
1.51-2.50
4=Exceeds Requirements
2.51-3.50
5=Exceptional
3.51-4.50
4.51-5.00
And Develops Solutions
Demonstrates Problem Solving
Skills
Offers Constructive
Suggestions For Improvement
Generates Creative Ideas And
Solutions
Provides Alternatives When
Making Recommendations
A. Total Number for each
column
B. Key Rating X
5
4
3
2
0
Total Performance Rating for
each column
PART II – CALULATIONS
Multiply each column’s total number of items in each column (A) by the key rating (B) for that column.
TOTAL OF
RATINGS
 12
x
NUMBER OF
RATED FACTORS
__25%
=
PART II
ASSIGNED WEIGHT
PART II
TOTAL SCORE
PART III - OVERALL EVALUATION
DIRECTIONS: Total Part I and Part II for your overall total evaluation score. Enter your overall score in the top
section of page one.
PART I TOTAL SCORE
(from Part I)
PART II TOTAL SCORE
(from Part II)
TOTAL SCORE
+
(Part I + Part II) =
Additional Comments:
Provide Suggestions For Self-Improvement:
Note: When setting goals for self- improvement, document a “by when date”. Supervisor please set a tickler to remind you to
review the employee’s progress within 2 weeks of the ‘by when date”.
Performance Evaluation
Associate Coordinator
10.2013/revised 11.2015
Page 5 of 6
PERFORMANCE EVALUATION
1= Unsatisfactory
Rating
Score
1.0-1.50
2=Marginal
1.51-2.50
Performance Key:
3=Meets Requirements
4=Exceeds Requirements
2.51-3.50
3.51-4.50
5=Exceptional
4.51-5.00
Supervisor/Manager Feedback:
Employee Comments
Verification of Review
By signing this form, you confirm that you have discussed this review in detail with your supervisor. Signing this form
does not necessarily indicate that you agree with this evaluation.
I,
agreement.
acknowledge receipt of review, and my signature does not necessarily indicate
Employee Signature
Date
Manager Signature
Date
Performance Evaluation
Associate Coordinator
10.2013/revised 11.2015
Page 6 of 6