Appraisal Form 13 – Fill Out and Use This PDF

Form 13	EMPLOYEE PERFORMANCE APPRAISAL
Revised (01/2006)	STATE OF ALABAMA
	Personnel Department
Employee Name: ________________________		Social Security Number: XXX-XX- ________________
Agency: _______________________________		Division:_____________________________________
Classification:___________________________		Class Code: __________ Position #: ______________
Period Covered From: _______ To: _________		Annual Raise Effective: _________________________

APPRAISAL SIGNATURES: Signatures are to be provided after the form has been completed. Signatures denote supervisor and employee discussion and receipt of form. Employee signature does not denote agreement. All signatures are mandatory.

Rating Supervisor	Employee	Reviewing Supervisor
SSN XXX - XX - _______		SSN XXX –XX- ___________
_______________________________		________________________________
Rater Signature		Reviewer Signature
_______________________________	___________________________	________________________________
Rater Printed Name	Employee Signature	Reviewer Printed Name
_______________________________	___________________________	________________________________
Date	Date	Date
_______________________________	___________________________	________________________________
Initial if comments attached	Initial if comments attached	Initial if comments attached

PERFORMANCE APPRAISAL SCORE: Locate the Responsibility Score on the back of this form and write it in the appropriate space. Locate the Disciplinary Score, also on the back of this form, and write it in the appropriate space. The Disciplinary Score is subtracted from the Responsibility Score to derive the Performance Appraisal Score. Mandatory documentation is to be maintained in the agency’s personnel files if a “Does Not Meet” or “Consistently Exceeds” rating is given.

0.0

-

0

=

0.0

Responsibility

Disciplinary

Performance Appraisal

Score

Score

Score

This employee’s work:

Does Not Meet

Partially Meets

Meets

Exceeds

Consistently

Standards

Standards

Standards

Standards

Exceeds Standards

(6.6 or below)

(6.7 – 16.6)

(16.7 - 26.6)

(26.7 - 36.6)

(36.7 - 40)

WORK HABITS: Check the appropriate space for each Work Habit area. Work Habits pertain to conduct occurring in this Appraisal period. Provide an explanation below for marking any work habit as “Unsatisfactory.” Attach additional sheets if necessary. No disciplinary action has to be taken to mark a Work Habit "Unsatisfactory."

	Unsatisfactory	Satisfactory
Attendance	____	____	__________________________________________
Punctuality	____	____	__________________________________________
Cooperation with Coworkers	____	____	__________________________________________
Compliance with Rules	____	____	__________________________________________

RESPONSIBILITIES: List an abbreviated version of the employee’s responsibilities below as documented on and discussed during the Preappraisal. Record the appropriate rating in the box for each responsibility. Rating(s) of appropriate responsibilities should reflect any disciplinary action(s) that has been taken during this appraisal period.

0	1	2	3	4
Does Not Meet	Partially Meets	Meets	Exceeds	Consistently Exceeds
Standards	Standards	Standards	Standards	Standards
Responsibility				Rating

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

5. _________________________________________________________________________

6. _________________________________________________________________________

7. _________________________________________________________________________

8. _________________________________________________________________________

9._________________________________________________________________________

10.________________________________________________________________________

RESPONSIBILITY SCORE:

0	÷	1	=	0.00	x	10	0.0
_______		______		______			= _______
Total of		Number of		Average			Responsibility
Responsibilities/Results		Responsibilities		Responsibility			Score
Ratings				Rating

DISCIPLINARY ACTIONS: Any disciplinary action taken with the employee during this appraisal period is to be documented below. Provide the number of disciplinary actions and steps taken with the employee during the appraisal year. If no disciplinary action has been taken, a “0” should be marked in each block provided. Attach a copy of the warning(s), reprimand(s), suspension(s) or demotion to the Appraisal.

Warning	Reprimand	Suspension	Demotion
0	0	0	0

DISCIPLINARY SCORE: This section should include the use of the discipline steps of reprimand, suspension,

and demotion only. The Disciplinary Score does not include scores for counseling and warnings. To calculate the Disciplinary Score, identify the most severe step of discipline taken with the employee during this appraisal period. If the most severe step was one or more reprimands, the Disciplinary Score will be 7. If the most severe step was one or more suspensions, the Disciplinary Score will be 17. If the most severe step taken with the employee in the appraisal year was one or more demotions, the Disciplinary Score will be 24. Otherwise, the Disciplinary Score will be 0.

DISCIPLINARY SCORE:	0
	_______