SAMPLE COMPLETED FORM
Employee Name Department, Job Title & Grade Evaluation Period Time in Position
Sarah Grant Internal Medicine, Account Asst, D July 2013 – June 2014 2 years
Supervisor Name & Title Dual Report Supervisor Name & Title
Jerry Santos
Instructions: The employee and supervisor should set work goals/objectives for the year and enter into section A. This section should be
reviewed during interim discussions and annual review at the end of the year.
SECTION A: CURRENT WORK GOALS/OBJECTIVES
1) Enhance clinical operations by improving accuracy of appointment time slots and appointment types entered into
the scheduling system. Reduce error rate from 10% to 5% monthly. Begin tracking in October 2013 after attending
refresher training for scheduling entry.
2) Improve customer satisfaction score by at least 3% in Q2, 2013 by notifying ALL patients whose appointments
could be delayed more than 1 hr through phone or text message.
3) By January 1, 2014, begin accurately entering referrals and level 2 complex appointments into the scheduling
system. Prepare by cross–training with Department X to learn referral and Level 2 scheduling processes.
NEXT CHECK-IN DATE: ___August 10, 2013_________
1
SECTION B: If your job requires a specific skill set or business knowledge due to governmental/institutional certification,
please attach any additional documentation.
Too
Soon Does Not Meet Partially Meets Meets Job Exceeds Job
to Rate Performance Dimensions Evaluator Job Expectations: Job Expectations: Expectations: Expectations:
Performance is inconsistent Performance is
or Unsatisfactory performance
and needs improvement
Successful performance
consistently outstanding
N/A
Communication:
Listens effectively and demonstrates the
Employee x
ability to express ideas orally and in writing
as required Supervisor x
Customer Service:
Courteous, helpful; understands and
Employee x
responds to the needs of customers and
colleagues Supervisor x
Dependability:
Reliable; understands assignments and Employee x
meets deadlines
Supervisory x
Initiative:
Self-starter, resourceful; develops ideas and Employee x
methods to enhance the work unit.
Identifies and participates in training
opportunities.
Supervisor
x
Job Knowledge:
Demonstrates understanding of
Employee x
responsibilities and expectations required
to do the job Supervisor x
Teamwork:
Works cooperatively with others and offers
Employee x
assistance and support when needed;
adaptable and open to change Supervisor x
Technical Skills:
Demonstrates proficient use of work
Employee x
related equipment, tools and/or technology Supervisor x
Work Quality: Employee x
Demonstrates accuracy, thoroughness and
attention to detail in a timely manner Supervisor x
2
SECTION C: EMPLOYEE INTERESTS/GOALS
I would like to cross-train to learn other department tasks such as referrals and scheduling of complex appointments. I
would also like to explore any additional courses available related to customer service such as dealing with a difficult
customer which can be a challenge at times.
SECTION D: SUPERVISOR - OVERALL PERFORMANCE AND COMMENTS
Sandy does a very good job overall. She exceeds expectations in Customer Service and Initiative. Sandy has achieved a
5% improved accuracy for scheduling patient appointments, and continues to contact patients in a timely manner
regarding changes to their appointments, which has helped us hit our target for increased customer satisfaction scores.
Sandy stands out in her ability to handle each patient encounter with courtesy and professionalism. She will benefit from
sharpening her written communication skills, and I will encourage her to look for training opportunities. Her cross-training
activity with others has enhanced her contribution to the department. I am happy to continue to support this interest.
EMPLOYEE COMMENTS
I am very pleased with my accomplishments this year. I have mastered scheduling complex appointments and understand
the referral process. I look forward to continuing to learn, increasing my skills, and providing the best possible service to
our patients. I am committed to improving my written communications over the next several months by attending a
Learning Center course and will explore other learning opportunities to improve this skill.
SECTION E: SIGNATURES
Supervisor(s) Signature: The contents of this form have been discussed with the staff member.
Jerry Santos 08/31/14
1. Supervisor: _______________________________________________________________________________________________________ Date: ___________________________
2. Supervisor’s supervisor: ________________________________________________________________________________________ Date: ___________________________
Employee’s Signature: My signature indicates I have completed these discussions with my supervisor, but does not necessarily imply my
agreement.
Sarah Grant 08/31/14
3. Employee: ________________________________________________________________________________________________________ Date: ___________________________
SECTION F: Check here to indicate whether you would like your Feedback Form shared with hiring managers as part of the reference
checking process.
____ ______ YES __________ NO INITIALS: _________S. G.____________________
