Individual Capture Form
This capture form enables employees to capture the performance
Conversations they have with their line manager throughout the year.
It is typically used by employees who do not have ‘Factor A’ and ‘Factor B’ outcomes.
Ahead of the performance conversation please ensure that you have prepared by thinking about your evidence, completing the form below, collecting
notes from supervisions and have a private room arranged with enough time to hold the meeting.
Employee Name
Job Title
Manager Name
Job Title
Team/BU
Date
Outcomes: Should be SMART - Specific, Measurable, Aligned, Realistic, Time-bound. They should contribute to the achievement of Bupa 2020
goals and be agreed with your line manager.
Outcomes
(What will you have achieved by the
end of the year to support our business
goals?)
Example:
Improve the standard of care
records on your unit
This will contribute to the following 2020
goals (please tick):
Measures
(How will
we evaluate
this?)
Care Record
standards
Timescales
for
achieving
Actions
(What will you do?)
Sharing your knowledge and
experience of how to create
excellent care records with all other
senior carers in the team.
End of August
Extraordinary
business
performance
Healthcare
partner to
millions
more
people
×
×
1
2
3
Mid-year check in & End of year review :
Use the spaces below and overleaf to record your progress, achievements and reflections at mid -year and end of year .
Employee Comments Mid Year:
Manager’s Comments Mid Year:
People
love
working
for Bupa
Progress
Session booked with 2
SC’s. 2 outstanding.
Employee Comments End of Year:
Managers Comments End of Year:
Employee’s Signature
Manager’s Signature
End of Year Appraisal rating: (Please
1 - Poor
Not meeting performance
or behavioural
expectations
Unacceptable performance
against outcomes
the appropriate rating)
2 – Inconsistent
Achieving in some areas
although overall
inconsistently meeting
performance and
behavioural expectations
Achieves outcomes in
some areas though not all
3 – Good
4 – Exceeds
Consistently achieving
performance and
behavioural expectations
Delivers good results
against outcomes
5 - Outstanding
Well above performance
and behavioural
expectations
Exceeds expectations
against stretching
objectives
Significantly above
performance and behavioural
expectations
Delivers outstanding results
against stretching objectives
Personal Development Plan:
Development Need
Please describe the
required areas requiring
development
Example:
Develop confidence with
residents who have
dementia.
Action Required
Describe the activities, steps or projects
that will help to gain this kind of
experience, where and when

Ask Barbara to coach me.

Read Person First Dementia Second

guidance booklet.
Visit the dementia unit at XX Home.
Support Required
What support is required & from
whom?

Manager to conduct 2
supervisions and provide
feedback.
Timescales
By October
Progress