Ad435 Form – Fill Out and Use This PDF

United States Department of Agriculture

1 Social Security No.

2 Position Number

3 Pay Plan

4 Occup. Series

Performance Appraisal

5 Name (Last, first, Middle Initial)

6 Grade/Step or Pay Level

7 Appraisal Period

From

To

8 Official Position Title

9 Organization Structure Code

10 Duty Station

11 Funding Unit

12 Agency Use

13 NFC Use

Instructions

Blocks 15B, 15C., 15D. Rate actual performance by entering

Blocks 1 through 10, completed by NFC,

2 for critical elements and 1 for non-critical elements

should be reviewed and, if necessary, corrected.

in appropriate column.

Block 11. enter funding unit number.

Blocks 15E, 15F, 15G. Enter total of each column.

Block 14. Enter brief description of performance elements.

Block 15H. Enter total from 15E, 15F and 15G.

Block 15A. Check performance elements identified

Block 16A. Check off the correct summary rating described in decision

as critical

table (16B).

Blocks 17 through 22. Self-explanatory.

15A

15B

15C

15D

14

Critical

Exceeds

Meets

Does Not

Performance Elements

Element

Fully

Fully

Meet Fully

()

Successful

Successful

Successful

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

16B Decision Table (check off Summary Rating in block 16A)

15E Exceeds

15F Meets

15G Does Not

Rating of Outstanding if 15E equals 15H.

Meet

Rating of Unacceptable 1/ if any critical element is rated in 15D.

Rating of Superior if no element is rated in 15D; 15F is greater

0

0

0

than zero; and 15E is greater than 15F.

Rating of Marginal 2/ if 15G is greater than 15E, and no critical

15H

element is rated in 15D.

15H Enter total

Rating of Fully Successful if none of the above apply.

15E + 15F + 15G = 15H

0

1/Unsatisfactory for SES

2/Minimally Satisfactory for SES

16A Summary rating (See Decision table in 16B)

17.

Employee (Check off appropriate box)

Outstanding

Yes

Superior

I have a copy of USDA and Agency regulations on employee

Fully successful

responsibilities and conduct; I have discussed them with my

supervisor and questions have been answered to my satisfaction.

No

Marginal

2/

Unacceptable 1/

18 Employee's Signature

Date

If employee did not sign, state reason.

1/ Unsatisfactory for SES

2/ Minimally Satisfactory for SES 17 Employee

(Check off appropriate box)

(Instructions for resolutions of disputes are on the reverse of employee copy.)

19a.

Supervisor's Signature

Date

19b.

Supervisor’s Name (Print)

20a. Reviewer's Signature

Date

20b. Reviewer’s Name (Print)

21

Approving Official's or

Date

22. FOR SES ONLY

Funding Unit Manager's Signature (optional)

PLA to ES

Bonus Amount

Check6JKUHQTOYCUFGUKIPGFappropriateWUKPI9QTF2GTHGEVcopy designationHQT9KPFQYU.

ORIGINAL

PERSONNEL

EMPLOYEE

SUPERVISOR

Form AD-435 (10/94)

75(5#