Creation of a Performance Evaluation Form

Preparation

  • Schedule an interview with each employee.
  • Provide each employee with a copy of this form for self-evaluation.
    Note: Self evaluation should be encouraged but not required.
  • Complete this form prior to interview, commenting briefly on all performance elements. Those elements
    checked “Needs Improvement” or “Exceeds Expectations” require comment.
    Note: Comments, negative or positive, should come as no surprise to the employee.
  • Review the completed form with your manager prior to the employee interview.
    Interview
  • Meet with employee privately and without interruption.
  • Review employee’s functional job description together with expectations and standards established and
    communicated at beginning of performance period.
  • Discuss completed appraisal form(s), allowing for employee input.
  • Encourage employee to make written comments on completed form.
  • Sign the form in employee’s presence and secure his/her signature.
    Completing the Form
  • If you use a word processor (PC) to complete this form, print a blank copy before you begin. This will
    ensure that your printer will print the form properly. Word processor font differences may affect the
    appearance of the form.
  • With the Rating Category Key as your guide, clearly mark (X) the appropriate box for each element.
    Remember that these are behavioral elements and that your judgment in each case must be supported by
    fact.
  • There are 23 performance elements for all employees and an additional 14 for supervisors and managers.
  • All 37 performance elements are stated at the “success” level and are to be considered the standard for
    “Meets Expectations.”
  • Summarize the data on the Rating Score Sheet.
    NLFPD EPA-3 Instructions – Page 1 April 2012
    New Lenox Fire Protection District
    EMPLOYEE PERFORMANCE APPRAISAL
    RATING CATEGORY KEY FOR FORM EPA-3
    Exceeds Expectations
  • This overall evaluation demonstrates job performance at a level exceeding that of a satisfactory
    evaluation. The employee’s performance regularly surpasses the standards expected.
    Meets Expectations
  • This overall evaluation demonstrates success and competency in the performance of the job. The
    employee has produced the desired or intended results and completely satisfies the established
    standards and expectations.
    Needs Improvement
  • This indicates an overall performance that is unacceptable due to the employee’s own lack of effort
    or skills. The employee has not met the standards as expected and must take immediate corrective
    action.
    NOTE: you will clearly mark (X) one of these three levels for each performance element (23 for all
    employees and an additional 14 for supervisors and managers). When you do so, you are comparing the
    employee’s actual performance to the standards and expectations established at the beginning of the
    performance period.
    This form is in a simplified MS® Word® format. Type in the boxes indicated. Since printers vary,
    we recommend you print a blank form to verify acceptable format.
    NLFPD EPA-3 Instructions – Page 1 April 2012
    New Lenox Fire Protection District
    EMPLOYEE PERFORMANCE APPRAISAL
    (Form EPA-3. Use this form for the final review of the performance period. See Instructions included with the form)
    Employee=s Name (Last, First, Middle) Social Security Number (last 4 digits only
    – to be completed by the employee)
    XXX-XX-_ _ _ _
    Position Title Time in Present Position (in months)
    Department: Type of Rating (Mark “X” below.)
    Division: Annual Probationary Special
    Section:
    Rating Period Supervisor’s Name Supervisor’s Title:
    RESPONSIBILITIES: Essential duties and responsibilities as identified in the functional job descriptions.
    PERFORMANCE STANDARDS and EXPECTATIONS: Objectives to be accomplished during the rating period.
    ACKNOWLEDGEMENT: A discussion of duties, responsibilities, performance standards, and expectations for the
    current period took place on:
    (Enter the signature date of the most recent EPA-1 Form above.)
    We acknowledge our understanding of these duties, responsibilities, standards, and expectations and how they will be
    used to measure work-related performance during this period.
    Supervisor=s Signature Date Employee=s Signature Date
    Performance Factors and Standards
    (Check or X)
    Needs
    Improvement
    Meets
    Expectations
    Exceeds
    Expectations
    MAINTAINS FLEXIBILITY
    Willingly accepts a variety of responsibilities.
    Adapts to new situations in a positive manner.
    Displays openness to learning and applying new
    skills.
    Works well with others to achieve
    organization=s goals.
    Is resourceful and generally seeks work process
    improvements.
    Comments:
    DEMONSTRATES CREDIBILITY
    Shares information with others when
    appropriate.
    Acts independently while keeping supervisor
    informed.
    Performs work according to current guidelines
    and directives.
    Maintains personal appearance appropriate to
    job.
    Exhibits ability to secure and evaluate facts
    before taking action.
    Comments:
    CUSTOMER SERVICE
    Treats all customers with respect.
    Responds to customer needs within agreed time
    frames.
    Addresses conflicts and problem situations with
    patience and tact.
    Comments:
    N LFPD Form EPA -3 (Word doc) April 201 2
    Performance Factors and Standards Needs
    Improvement
    Meets
    Expectations
    Exceeds
    Expectations
    QUANTITY OF WORK
    Work output matches the expectations
    established.
    Employee completes all assignments.
    Employee consistently meets deadlines.
    Comments:
    QUALITY OF WORK
    Work results satisfy organization=s goals.
    Work is organized and presented professionally.
    Work product is thorough and complete.
    Work product is free of flaws and errors.
    Comments:
    AVAILABILITY FOR WORK
    Employee=s attendance supports the expected
    level of work.
    Employee=s presence can be relied upon for
    planning purposes.
    Employee is a dependable team member.
    Comments:
    N LFPD Form EPA -3 (Word doc) April 201 2
    In addition to the 23 performance elements for all employees, supervisors and managers shall be
    rated on the following critical success factors: (1) Leadership, (2) Management, and (3) Work
    Environment. Check the appropriate box for each of the 14 performance elements.
    Performance Factors and Standards Needs
    Improvement
    Meets
    Expectations
    Exceeds
    Expectations
    LEADERSHIP
    Provides clear direction and purpose.
    Models ethical workplace behavior.
    Demonstrates influencing skills by setting goals.
    Empowers subordinates to achieve objectives.
    Acts to motivate, coach, and develop
    subordinates.
    Comments:
    MANAGEMENT
    Organizes and distributes work among
    subordinates.
    Secures resources and audits their effective use.
    Communicates behavioral expectations and
    performance standards.
    Monitors, documents, and evaluates employee
    conduct and performance.
    Provides appropriate and timely feedback.
    Comments:
    WORK ENVIRONMENT
    Maintains a safe and healthy workplace.
    Builds a team that reflects high morale, clear
    focus, and group identity.
    Encourages and provides opportunities for
    subordinates to obtain and apply new skills and
    knowledge.
    Promotes equal opportunity and protects the
    rights of all employees.
    Comments:
    N ew Lenox Fire Protection District
    EMPLOYEE PERFORMANCE APPRAISAL
    RATING SCORE SHEET FOR FORM EPA-3
    Enter the total check marks in each rating category and then multiply by the assigned value.
    Rating Categories Count Multiplier Category
    Totals
    Exceeds Expectations X 3 =
    Meets Expectations X 2 =
    Needs Improvement X 1 =
    Total Elements Rated = Total Value =
    (Total Value ) Total Elements) Rating Score =
    Compute the Rating Score: Divide the total value by the total elements rated (23, 37) to find the
    overall rating score. (Example: 44 ) 23 = 1.91).
    Make certain that you have carried your figure out to two decimal places.
    Using the key below, find the numeric score and enter it as the Overall Rating, then enter the
    Alpha Score:
    Key:
    Numeric Score Alpha Score
    Rating of 2.51 to 3.00 = Exceeds Expectations
    Rating of 1.51 to 2.50 = Meets Expectations
    Rating of 1.00 to 1.50 = Needs Improvement
    Summary:
    Overall Rating Score
    Alpha Score
    NLFPD Form EPA-3 (Word doc) April 2012
    N ew Lenox Fire Protection District
    EMPLOYEE PERFORMANCE APPRAISAL
    Needs Improvement Meets Expectations Exceeds Expectations
    Summary Comments: Completed by supervisor or rater.
    Improvement and/or Developmental Plan: Completed by supervisor or rater.
    Reviewing Manager’s Initials: Date:
    Employee’s Response: Completed by employee
    Employee’s Certification:
    I certify that I have reviewed this Performance Appraisal Form. My signature on this page implies neither
    my agreement nor my disagreement with the form=s contents.
    Supervisor’s Signature Date
    Employee’s Signature Date
    Reviewing Manager=s Signature Date
    NLFPD Form EPA-3 (Word doc)

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