Responsibility - 360 Degree Feedback Survey Sample #8

Questionnaires Measuring Responsibility:
Survey 1 (4-point scale; Competency Comments)
Survey 2 (4-point scale; Competency Comments)
Survey 3 (5-point scale; Competency Comments)
Survey 4 (5-point scale; radio buttons)
Survey 5 (4-point scale; words)
Survey 6 (4-point scale; words)
Survey 7 (5-point scale; competency comments; N/A)
Survey 8 (3-point scale; Agree/Disagree words; N/A)
Survey 9 (3-point scale; Strength/Development; N/A)
Survey 10 (Comment boxes only)
Survey 11 (Single rating per competency)
Survey 12 (Slide-bar scale)

You have been selected to provide feedback for the manager listed above. Your feedback is an important part of 's leadership development process. This tool is intended to gather broad feedback in the core competencies and role responsibilities that are important for the on-going success of our organization.

In responding to the assessment form, please think about your experiences working with this individual during the last six to twelve months. Your responses will be merged with other people's feedback and presented to to guide them in their on-going development. Comments will be shared anonymously, as written, with the manager.

Sample Result Document:
Sample Results
Method of use: As part of the review process, managers will receive feedback from peers and staff. It is recognized that not all participants will be able to assess an individual's performance in all areas. The feedback received will be utilized as input to the manager's performance and on-going development plan.

You may sign out at any time by pressing the Save button at the end of the form and then closing your browser. You may return later to pick up where you left off. When you are done, press the Complete button.

When clicking your selection below, try to best fit the manager's actual behaviors to the scale provided.

If you are not sure, or unable to assess, select "Not Applicable" (N/A) option.

Please complete your response by .


Agree Unsure Disagree N/A
  1. Holds herself / himself accountable to goals / objectives
  1. Sets a good example.
  1. Responsible for setting the vision of the department.
  1. Sets a good example
  1. Acts as a resource without removing individual responsibility.

Interpersonal Skills

Agree Unsure Disagree N/A
  1. Builds a strong rapport with co-workers.
  1. Demonstrates willingness to work with others.
  1. Successfully resolves conflicts and grievances to a win-win solution.
  1. Provides constructive feedback in a way that fosters acceptance and development.
  1. Is a role model for others


Agree Unsure Disagree N/A
  1. Conducts regular performance appraisals and feedback.
  1. Helps employees to understand responsibilities, authority, and expectations.
  1. Addresses employee behavior problems effectively.
  1. Helps employees to maintain high personal standards.
  1. Coaches employees in how to strengthen knowledge and skills to improve work performance.


Agree Unsure Disagree N/A
  1. Able to adapt to new situations.
  1. Acts decisively in frequently changing and uncertain environment.
  1. Willing to try new ideas.
  1. Adapts to new organizational structures, policies, or procedures.
  1. Effective in incorporating new ideas.


Agree Unsure Disagree N/A
  1. Analyze what occurred and re-adjusts accordingly when goals are not met.
  1. Always strives to produce the highest quality work products.
  1. Reflects on what is working and what could be improved.
  1. Encourages others to achieve high quality standards.
  1. Encourages employees to produce the best quality products.

Problem Solving

Agree Unsure Disagree N/A
  1. Generates alternative solutions to problems and challenges.
  1. Actively seeks the root cause of a problem.
  1. Solves problems using logic and insight.
  1. Ability to develop innovative solutions to problems.
  1. Able to balance the needs of different people in a solution to a problem.

Results Oriented

Agree Unsure Disagree N/A
  1. Explains the "whys" behind organizational objectives
  1. Directs team in prioritizing daily work activities
  1. Stays focused on meeting the needs of customers.
  1. Helps others when free-time is available.
  1. Does not become distracted by non-issues or interruptions.


Agree Unsure Disagree N/A
  1. Treats others with respect and dignity.
  1. ...treats others with respect and dignity.
  1. Able to see issues from others' perspectives.
  1. Includes others in the decision making processes.
  1. Works effectively with people from other departments.

Global Perspective

Agree Unsure Disagree N/A
  1. Develops both the cultural awareness and business skills to grow our business in all countries, and work effectively across borders with employees, customers, and shareowners.
  1. Aligns personal vision with global strategies.
  1. Able to listen and understand others and discuss issues in a respectful way.
  1. Comfortable using teleconferencing equipment to facilitate meetings with others abroad.
  1. Can effectively deliver presentations to international clients.

  1. Overall, please rate the effectiveness of [Participant Name Here].

  2. Strengths

  3. Areas for Development

  4. Please give any final comments or suggestions for [Participant Name Here]'s assessment.