Safety - Performance Management Assessment Sample #10

Performance Assessments that include Safety:
Assessment 1 (5-point scale; IDP Comments)
Assessment 2 (3-point scale with Comments)
Assessment 3 (Manager Assessment; 360-Feedback)
Assessment 4 (3-point scale; Rating Limits)
Assessment 5 (3-point scale; Rating Limits)
Assessment 6 (5-point scale with Comments)
Assessment 7 (Comment Boxes Only; IDP)
Assessment 8 (Comment Boxes Only)
Assessment 9 (3-point scale with Letter Grade)
Assessment 10 (360-Feedback; Bonus/Merit Pay)
Assessment 11 (Core Values & Job Competencies)
Assessment 12 (4-point scale; 6 Comment Boxes)

Performance Management System
Supervisor: [Supervisor Name] Signature: ___________________ Date: _____________	Employee: [Employee Name] Signature: ___________________ Date: ___________
Job Title: Mid-Level Manager in X Department	Hire Date:

Instructions:

This performance appraisal program is designed to provide a standardized method to:
Provide an objective evaluation of an employee's performance and to share this feedback with the employee
Assist in determining the true development needs of the employee and actions that should be taken to improve their job performance.
This form is intended to ensure fair and equitable salary management. Please note that this review is one of several factors considered in salary decisions.

Employee Input
Please provide brief answers to the questions below. Your feedback is vital to us. We aim to capture all your achievements during the performance review period. The details you enter will be part of your Performance Appraisal. If you need to include any additional printed sheets, please sign, date, and submit them to your Department Head. Additionally, if someone else should contribute to this review, kindly provide their name and contact details.

Part 1: Status Recommendation

If currently on Probational Status:

Remove from Probationary Status

Extend Probationary Status to Date:

If on Regular Employment Status:

Continue Full-Time Status

Continue Part-Time Status

Develop Corrective Action Plan1

Continue Corrective Action Plan; to be reviewed on Date:

Reinstate Previously Formulated Corrective Action Plan1

Recommend Termination of Employment1

Justification for the above Status Recommendation:

Competencies Included:
Safety, Initiative, Customer Focus, Strategic Insight, Accountability

Part 2: Results of 360-Degree Feedback

Safety: Mitigates hazards and safety issues that arise. Ensures compliance with safety regulations. Is aware of OSHA safety guidelines. Is not afraid to question a potential safety issue observed in the workplace.

Initiative: Initiates draft documents for the director. Actively works on resolving the issue instead of procrastinating or hoping it will resolve itself. Acts quickly when an opportunity becomes available. Acts quickly when a small problem arises to keep it from becoming a major issue.

Customer Focus: Creates innovative solutions to meet customer needs. Prioritizes the needs and preferences of the customer. Transparent in all communications with the customer. Is committed to resolving customer issues in a positive way.

Strategic Insight: Analyzes records and reports to obtain insight into potential issues and trends. Inspires employees to adopt the strategic plan. Identifies potential problems before they become critical incidents. Identifies root causes of problems.

Accountability: Works to achieve established goals. Commits to leading the initiatives to solving critical issues. Acts like an owner when they make decisions. Holds employees accountable for meeting performance benchmarks.

Part 3: Summary of 360-Degree Feedback

Part 4: Bonus Pay

The supervisor now must consider which of the following adjustments to make to compensation.
Changes made here are reflected in the Salary Recommendations section at the beginning of this form.

Midpoint of Scale Status

Consider eligibility for Movement to Midpoint:

Yes: If Yes, continue with this section below
No, If no continue to next section

Depending on your responses, the computer may show (or hide) certain elements of the form.

Already at Midpoint:

Yes: If Yes, continue on to Merit Pay Section
No: If No, continue within this section directly below

Movement to Midpoint Recommended:

Yes: If Yes, enter supporting rationale below and then go to Merit Pay Section
No: If No, enter supporting rationale and stop here.

Rationale:

Merit Pay Section

When this form was initially loaded, the employee was eligible for Merit Pay.
However, if the scores on Job Performance Criteria were too low, then the eligibility would change.

Consider eligibility for Merit Pay:
Yes: If Yes, continue with this section below
No, If no continue to next section

Change the scores on Job Performance Criteria to see how it affects this section.

Based on automated scoring % Merit Pay is Recommended

Merit Pay Recommended:

Yes: If Yes, specify amount below and enter justification
No: If No, enter supporting rationale and stop here.

Merit Pay Recommended in the amount equal to % of current base pay.

Rationale:

Experience Pay Section

Eligible for Experience Pay:

Yes: If Yes, continue with this section below
No, If no continue to next section

Experience Pay Recommended:

Yes: If Yes, specify amount below and enter justification
No: If No, enter supporting rationale and stop here.

Experience Pay Recommended in the amount equal to % of current base pay.

Rationale:

Part 5: Individual Productivity and/or SMART Goals

Employee Comments

Supervisor Comments

Part 6: Team Productivity and/or SMART Goals

Employee Comments

Supervisor Comments