PERFORMANCE APPRAISAL FORM 1 (C )

FOR FACULTIES IN MEDICAL EDUCATION SERVICE

PART 1

APPRAISAL OF

Medical Education Service Shri………………………………………………( in Block letters)

Department…………………………… for the period …………………………………………………

Name :
Date of birth :
Post :
Date of entry in Government Service :
Date of appointment to the present post :
Date of entry in the present Department :
Pay and scale of pay :
Date from which functioning in the present
Cadre continuously :

List of subjects dealt with according to the

Office order distributing work :
EDUCATIONAL AND OTHER QUALIFICATIONS
General Department Special Other skills if any
1.

2.

3.

EXPERIENCE
Department Category of Work Period
----------------------------
From To
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Performance Appraisal Form

Organization: Department:
Employee Name: Designation:
Duration in the present post: Total length of service:
Period of assessment: Date of assessment:

1. For each of the items listed below, please comment on the employee’s performance, along with
suggestions for improvement.
(A =Outstanding B=Exceeds Expectations C=Meets Expectations D=Improvement Needed)

No. Domain A B C D

1. Job Knowledge

2. Technical Skills

3. Quality of work

4. Productivity or
Work Output

5. Initiative and Creativity

6. Problem Solving skills
7. Leadership capability

8. Team work
9. Attendance

10. Dependability
11. Work Ethic

12. Adherence to institutional

Policy
13. Commitment
14. Professional Growth
Total Score

Overall Performance – Rate employee’s overall performance in comparison to position duties and responsibilities

Outstanding Exceeds Expectations Meets Expectations Improvement Needed.

 -3-

2- List and describe the employee’s top three accomplishments during the rating period:

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

3. List and describe the employee’s three greatest strengths, giving specific examples of how the employee uses
these strengths in his or her position.

1. ___________________________________________________________________________

2. ___________________________________________________________________________
3. ___________________________________________________________________________

4. Identify 3 - 5 goals for the next review year, along with an action plan for accomplishing each one.
1. ___________________________________________________________________________
_________________________________________________________________________
2. ___________________________________________________________________________

___________________________________________________________________________
3. ___________________________________________________________________________

___________________________________________________________________________
4. ___________________________________________________________________________

___________________________________________________________________________

5. __________________________________________________________________________
___________________________________________________________________________
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5. Employee comments
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Completed by:

________________________________ ________________________________
Employee Name (Please Print) Signature with Date

________________________________ ________________________________
Head of Dept. (Please Print) Signature with Date

Supervisor’s overall rating and comments (Not be reported to the employee)

________________________________ ________________________________
Head of Dept. (Please Print) Signature with Date

Reviewer’s overall rating and comments

________________________________ ________________________________
Reviewer (Please Print) Signature with Date
 -5-
Employee Self Evaluation Form
Please provide thoughtful responses to the following questions. The information you provide will be used to
help develop your performance and career development goals for the next year.
Part 1: Career Development
1. What steps have you taken since your last review to improve yourself as relates to your current position?
(Mention new qualifications, promotions, awards and honors)
________________________________________________________________________
_______________________________________________________________________________________
_________________________________________________________
2. What outcomes and improvements have you seen as a result of the actions described above?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. What are the projects and publications you have undertaken during the past year?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

4. What goals would you like to set for yourself to accomplish during the next review period?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
__________________
5. What can your supervisor do to help ensure that you are making
progress towards accomplishing your professional development goals?
________________________________________________________________________

________________________________________________________________________
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Part 2: Performance Traits
1. How would you rate yourself in terms of consistency?
1 2 3 4 5
Deficient Needs improvement Not strong or weak About average Outstanding

2. How would you rate yourself in terms of professional communication skills?

1 2 3 4 5
Deficient Needs improvement Not strong or weak About average Outstanding

3. How would you rate yourself in terms of technical skills?

1 2 3 4 5
Deficient Needs improvement Not strong or weak About average Outstanding

4. How would you rate yourself in terms of organizational skills?

1 2 3 4 5
Deficient Needs improvement Not strong or weak About average Outstanding

5. How would you rate yourself in terms of reliability?

1 2 3 4 5
Deficient Needs improvement Not strong or weak About average Outstanding

6. How would you rate yourself in terms of being a team player?

1 2 3 4 5
Deficient Needs improvement Not strong or weak About average Outstanding

Part 3: Additional Comments

Please provide any additional comments or feedback that you would like to share.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________________
Submitted by:
__________________________________________ ______________
Employee Name (Please Print) Signature
Date

__________________________________________ ______________
Head of Department (Please Print) Signature
Date