Annual Performance Appraisal

EMPLOYEE PERFORMANCE EVALUATION FORM REVIEW PERIOD (20– 20)

Name: Department: Title: Supervisor: DOH in Position: Date:

SECTION I: PERFORMANCE ASSESSMENT PART A: CORE COMPETENCIES The 8 core competencies listed below are vital to the success of all county employees. Please rate the employee’s performance with respect to each of the core competencies. Please note that comments in this section are required for ratings of Unsatisfactory, Provisional (New Employee), Minimally Acceptable, Fully Competent, Commendable, or Outstanding.

Accountability Comments Rating Select From Drop Down . Provides work that is accurate and purposeful; Shows initiative; takes ownership of all responsibilities . Performs tasks thoroughly and on time; Works within departmental guidelines; Seeks input and acts upon feedback . Enhances personal knowledge, skills and abilities . Follows through on responsibilities and tasks in an effective manner . Is reliable and performs responsibilities as specified in job description

Collaboration Comments Rating Select From Drop Down . Serves as a positive team member and/or colleague . Treats co-workers with respect, honesty and fairness . Establishes productive working relationships . Is flexible and adapts to changing priorities . Resolves conflicts effectively

Communication Comments Rating Select From Drop Down . Communicates verbally and in writing at a level appropriate for his/her position . Follows instructions and shares information if appropriate . Engages in meaningful, two-way conversations . Speaks effectively, understands others, listens attentively and clarifies information when necessary

County Values Comments Rating Select From Drop Down

of 6 . Projects a positive image of Luzerne County . Embraces a commitment to maintain a diverse and inclusive workplace . Understands and complies with County health and safety policy and programs . Reports to work as scheduled, requests and uses leave appropriately

Service Comments Rating Select From Drop Down . Is accessible, offers assistance and support, and makes self available to respond to customer/client needs . Maintains courtesy and diplomacy with internal and external customers/clients and responds in a timely and helpful manner . Strives to provide exceptional service to prevent unnecessary delays for customers/clients . Demonstrates positive behavior and demeanor . Promotes cooperation, collaboration and flexibility with contacts and colleagues Organization Comments Rating Select From Drop Down . Adheres to priorities and deadlines . Plans and schedules work for self to meet department objectives and goals; Follows through on assignments . Produces neat, accurate, thorough, organized work and eliminates unnecessary duplication . Demonstrates flexibility in responding to priorities and organizational change Initiative/Problem Solving Comments Rating Select From Drop Down . Expends the effort and time necessary to do the job well. . Able to work independently or within a group . Able to analyze and define problem areas and establish solutions . Utilizes job knowledge and sound reasoning to analyze situations, resolve problems, and reach decisions Job Skills and Knowledge Comments Rating Select From Drop Down . Possesses knowledge and skills to produce quality work . Able to perform wide variety of job related tasks . Demonstrates knowledge and understanding of job duties, equipment, and appropriate work methods

PART B: JOB SPECIFIC COMPETENCIES AND ACHIEVEMENT OF GOALS* Please list and rate the employee’s performance regarding the top 3 critical responsibilities in his/her job description. When assessing the employee’s performance, please consider the following factors: job knowledge; quality of work; judgment; and utilization of technology when available and appropriate. In the final row, please assess the employee’s performance with respect to goals for the current review period. Please note that comments in this section are required for Unsatisfactory, Provisional (New Employee), Minimally Acceptable, Fully Competent, Commendable, or Outstanding.

Job Responsibility 1 Comments Rating . . . Select From Drop

of 6 .

. Job Responsibility 2 Comments Rating . . . Select From Drop

Down . .

. Job Responsibility 3 Comments Rating . . . Select From Drop . Down . . . . .

. Goals Comments Rating

. . Identifies meaningful goals . . Select From Drop . Modifies goals to meet changing needs Down . Pursues training and development opportunities . . Achieves established goals

. . *If you determine that the employee’s job description does not accurately reflect his/her current duties and responsibilities, you should submit a revised draft to the Human Resources Department for review...... Part C: Supervisory Competencies Not Applicable ☐ . . The following competencies are vital to the success of all individuals who supervise employees. Please rate the employee’s performance with respect to the supervisory competencies listed below. Please note that comments in this section are required for Unsatisfactory, Provisional (New Employee), Minimally Acceptable, Fully Competent, Commendable, or Outstanding. . . . Managing Performance Comments Rating . . . Select From Drop . Holds employees accountable Down . Provides timely, constructive and balanced feedback . Completes performance evaluations honestly and fairly . . Works with employees to prioritize and revise goals . Maintains accurate records relative to performance . Identifies training and development opportunities . Controls operating costs by effectively utilizing staff, material, and equipment . Carefully monitors expenditures and works within budgetary constraints . Communicates and ensures compliance with County policies/procedures . Leadership Comments Rating Page 3 of 6 . . . Select From Drop

. Provides positive leadership, support and direction Down . Plans, controls and delegates effectively . . Motivates employees to perform at the highest level . Manages conflicts between employees effectively . Sets a positive example for employees under supervision . Promotes respect, honesty, integrity, and fairness . Effective in addressing personnel issues with coaching and discipline as appropriate . Supports County mission, goals, and objectives ...... SECTION II: OVERALL PERFORMANCE APPRAISAL RATING* . . Please provide an overall performance rating taking into consideration your assessment of the competencies in Section I, as well as the goals identified for the review period. You may only select one rating from the group below. . . . ☐ . ☐ Provisional . ☐ . ☐ Fully . ☐ . ☐ Outstanding Unsatisfactor . (New Minimally Competent Commendable y Employee) Acceptable . o Overall Performance Appraisal o Summary and Comments *

...... *Human Resources must review and approve overall ratings of Unsatisfactory or Outstanding, prior to being issued. . . SECTION III: PERFORMANCE IMPROVEMENT ACTIONS . . Please use this section only for employees with overall ratings of Fully Competent and above to identify and detail actions required/recommended to improve performance based on performance factor ratings in Section II.

of 6 o Performance Improvement Actions

......

. O . SECTION IV: TRAINING AND DEVELOPMENT OPPORTUNITIES . o Training and Development Opportunities

. . . . .

. . SECTION V: EMPLOYEE’S COMMENTS . . Employee’s Comments

. . . .

. . . . . O SIGNATURES AND VERIFICATIONS . . I have been advised of my performance ratings. I have discussed the contents of this review with my supervisor. My signature does not necessarily imply agreement. I was given an opportunity to provide comments in Section V above. . .

of 6 . Employee: Date: . . . I have drafted and discussed this performance appraisal with the above named employee. . . . Supervisor: Date: . . I have read and approved this performance appraisal. . . . Department/Division Head: Date: . . . APPENDIX I: ESTABLISHMENT OF GOALS/OBJECTIVES/SPECIAL ASSIGNMENTS FOR THE COMING YEAR . . List below the goals, objectives, or special assignments which should be continued and/or completed in the coming year. It is understood that these goals, objectives, etc. are subject to adjustment or change as situations and priorities change.

o Goals/Objectives/Special Assignments

......