Form Phs 838 PDF Details

Form Phs 838 is a form used to request an exemption from paying the individual shared responsibility payment for not having health insurance. This form can be used by individuals who have coverage through their employer or other source, and meet certain criteria. Individuals who do not have coverage and do not qualify for an exemption may have to pay a penalty. The purpose of this form is to exempt individuals from having to pay this penalty. For more information on Form Phs 838, visit our website or contact us today. We would be happy to assist you!

QuestionAnswer
Form NameForm Phs 838
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesCCMIS, phs 838 form, PHS-838, phs 838

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Department of Health and Human Services Commissioned Corps of the U.S. Public Health Service

Officer’s SERNO

Commissioned Officers’ Effectiveness Report

 

SECTION 1. ADMINISTRATIVE DATA: Required.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART I. OFFICER ADMINISTRATIVE INFORMATION.

 

 

 

 

 

 

 

 

 

a. Name and Rank of Rated Officer (Last, First, MI, Rank):

b. Period Covered by Report

(MM/DD/YY):

 

 

 

 

 

 

 

 

 

 

From ______________________

To ______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Type of Report

(Check only one):

Annual

Officer Transfer

Supervisor Transfer

Interim

Other ______________________

 

 

 

 

 

 

 

 

 

 

d. HHS Division or Non-HHS Organization for Report Period:

e. Position/Billet Title for Report Period:

 

 

 

 

 

 

 

 

 

 

 

 

f. Position/Billet Grade for Report Period (check highest):

g. In current billet since (MM/DD/YY):

 

 

 

 

O - 1 O - 2

O - 3 O - 4

O - 5 O - 6

O - 7 O - 8

 

 

 

 

 

__________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART II. RATER’S COMMENTS AND SIGNATURE.

 

 

 

 

 

 

 

 

 

a. Name and Job Title of Rater (Last, First, MI, Title):

 

b. Phone Number:

 

 

c. Time supervising this officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______ Years ______ Months

 

 

 

 

 

 

 

 

 

 

 

 

d. Please rate the officer’s overall performance of job duties during the report period.

Satisfactory

Marginal

Unsatisfactory

 

 

 

 

 

 

 

 

e. Strengths: List the areas in which the officer displays strong qualities and superior skills. (3 lines = 240 Courier New 10 pt. characters)

 

 

 

 

 

 

 

 

f. Areas for Improvement: List the areas needed for continued growth and development. (3 lines = 240 Courier New 10 pt. characters)

 

 

 

 

 

 

 

 

 

 

g. Signature / Date

 

_____________________________________________________________________

___________________

 

 

 

 

 

 

 

 

 

 

PART III. RATED OFFICER’S SIGNATURE and CONCURRENCE / NON-CONCURRENCE.

 

 

 

 

a. Select one option.

 

 

I concur with this rater's evaluation.

 

 

 

 

 

 

 

 

 

 

 

 

 

I disagree with this evaluation and reserve the right to file a rebuttal.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Signature / Date

 

I have read this review and have had the opportunity to discuss it.

 

 

 

 

 

 

 

 

 

 

 

_____________________________________________________________________

___________________

 

 

 

 

 

 

 

 

PART IV. REVIEWING OFFICIAL’S COMMENTS, SIGNATURE AND CONCURRENCE / NON-CONCURRENCE.

 

 

a. Name and Job Title of Reviewing Official (Last, First, MI, Title):

 

 

 

 

b. Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Select one option.

 

 

I concur with this evaluation.

 

 

 

 

 

 

 

 

 

 

 

 

 

Although this evaluation is reasonable, this rater is somewhat more demanding than average.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Although this evaluation is reasonable, this rater is somewhat less demanding than average.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I disagree with this evaluation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Reviewing Official’s Comments.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Signature / Date

 

__________________________________________________________________

_________________

 

 

f. Agency Liaison / Date

 

__________________________________________________________________

_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHS-838 (Rev. 07/2010)

 

 

 

 

 

 

 

 

 

 

Page 1 of 4

Department of Health and Human Services

Commissioned Corps of the U.S. Public Health Service

Commissioned Officers’ Effectiveness Report

SECTION 2: OFFICER ’S COMMENTS: To Be Completed by Officer.

Officer’s SERNO

OFFICER INSTRUCTIONS: Describe your duties, goals and accomplishments during the performance period. Use the space provided. Additional pages will be discarded.

Description. Describe the main duties and responsibilities in your job during the performance period. (5 lines = 400 Courier New 10 pt. characters)

Goals. List your work-related goals for the next performance period and long term career goals. (5 lines = 400 Courier New 10 pt. characters)

Accomplishments. List your accomplishments related to the elements you will be rated on in section 3. (21 lines = 1680 Courier New 10 pt. characters)

PHS-838 (Rev. 07/2010)

Page 2 of 4

Department of Health and Human Services

Commissioned Corps of the U.S. Public Health Service

Commissioned Officers’ Effectiveness Report

Officer’s SERNO

SECTION 3: PERFORMANCE EVALUATION: To Be Completed by the Rater. Optional if period of supervision is less than 6 months.

RATER INSTRUCTIONS : Rate the officer in relation to the needs of the position as follows: 1 = Unsatisfactory range; 2 to 3 = Adequate range; 4 to 5 = Effective range; 6 to 7 = Exceptional range. Fill in only one circle per element. To assist you, guidance for adequate, effective and exceptional performance is presented. Number ratings without narrative guidance are to be used when an Officer is performing either above or below the level specified by numbered comments, as judged by the Rater. Comments are required. Describe the action(s) upon which you based your rating. Be specific so that there is a clear connection between the Officer’s actions and your rating. Use the space provided at the end to comment.

1.Leadership - Demonstrates and communicates vision and sense of purpose; nurtures an environment conducive to accomplishing the organization’s mission.

 

 

- Demonstrates behavior that

 

- Demonstrates behavior that facilitates

 

- Consistently demonstrates behavior that

 

 

 

maintains the status quo, often

 

collaboration, fairness, and inclusiveness.

 

contributes to the organization’s success by

 

 

seeking direction in accomplishing

 

- Influences others through actions,

 

fostering effective relationships, inspiring

the

 

 

the team’s goals.

 

accomplishments, and team work.

 

trust of others, and nurturing group

 

 

 

- Has minimal influence on others.

 

 

 

effectiveness and cohesion.

 

 

 

 

 

 

 

- Influences others by exhibiting vision,

 

 

 

 

 

 

 

innovation, resilience, inclusiveness, and by

 

 

 

 

 

 

teaching and coaching others.

 

 

2.Initiative and Growth - Recognizes and acts on programmatic and personal developmental needs, resulting in advancement of programmatic goals and growth in professional skills.

 

 

- Needs assistance in identifying

 

- Recognizes opportunities for growth and

 

- Independently seeks out and completes

 

 

opportunities to improve work

 

seeks experiences to improve work

 

challenging opportunities that broaden

 

 

performance.

 

performance.

 

expertise, maximize job performance, and

 

 

- Work performance improves with

 

- Willingly incorporates new approaches

 

enhance value to the program.

 

 

 

regular supervisory input and

 

and responsibilities to advance program

 

- Anticipates program needs including

 

 

 

goals. Requires minimal supervision and

 

potential barriers. Proactively and decisively

 

 

detailed instructions about

 

 

 

 

 

seeks guidance with solutions only for

 

implements innovative solutions

to improve

 

 

assignments.

 

 

 

 

 

unexpected barriers.

 

work processes with impact beyond scope

 

 

- Needs guidance to understand how

 

 

 

 

 

- Accepts responsibility for personal

 

of assigned responsibilities.

 

 

 

personal decisions and actions

 

 

 

 

 

 

decisions or mistakes and learns from

 

- Actively identifies personal role in a

 

 

contribute to mistakes or impedes

 

 

 

 

 

errors.

 

problem and contributes to the solution,

 

 

success of individual and group

 

 

 

 

 

 

 

enhancing the successful outcome of

 

 

projects.

 

 

 

 

 

 

 

 

individual and group projects.

 

 

 

 

 

 

 

 

 

3.Communication Skills - Conveys clear and succinct written and verbal messages that are appropriate to the audience. Listens to and understands information from others.

 

 

 

 

- Needs assistance in expressing

 

- Tailors communication (verbal and

 

- Organizes and expresses complex ideas,

 

 

 

main thoughts clearly, both orally

 

written) to the level and experience of the

 

both orally and in writing, to successfully

 

 

 

and in writing, and clarifying the

 

audience, ensuring that messages are

 

inform and influence individual and

 

 

 

 

meaning and intent of others'

 

organized, useful and accurate.

 

managerial decisions that advance the

 

 

 

 

communication.

 

- Utilizes strong listening skills to formulate

 

organization’s mission.

 

 

 

 

- Uses correct spelling, grammar,

 

direct, responsive answers to questions.

 

- Is a confident and effective speaker, asks

 

 

 

 

 

open-ended questions, and recognizes and

 

 

 

and punctuation to create simple

 

 

 

 

 

 

 

 

 

accommodates a vast diversity of ideas and

 

 

 

documents.

 

 

 

 

 

 

 

 

 

traditions.

 

 

 

 

 

 

 

 

 

 

4.

Interpersonal Skills - Facilitates relationships in a manner that motivates others to maximize their abilities, skills, and knowledge to affect the desired

outcomes.

 

 

 

 

 

 

 

 

 

 

- Prefers work activities that can be

 

- Participates in group activities,

 

- Promotes collaboration by demonstrating

 

 

 

completed independently and does

 

demonstrates respect for others, and

 

respect, friendliness, appreciation, humor,

 

 

 

not require sustained interaction with

 

receives and offers constructive feedback,

 

empathy, and a positive attitude. Serves as

 

 

 

individuals of differing viewpoints or

 

which contributes to the achievement of

 

a mentor to others.

 

 

 

 

opinions.

 

organizational goals.

 

- Is cognizant of the needs of others and

 

 

 

- Minimally contributes to the

 

- Contributes to the resolution of conflicts.

 

works to ensure equal treatment of all

within

 

 

 

resolution of conflicts or

 

 

 

the work environment. Serves as mediator in

 

 

 

disagreements.

 

 

 

resolving conflicts.

 

 

 

 

 

 

 

 

 

 

 

PHS-838 (Rev. 07/2010)

Page 3 of 4

Department of Health and Human Services

Commissioned Corps of the U.S. Public Health Service

Commissioned Officers’ Effectiveness Report

Officer’s SERNO

5.Planning and Organization - Balances workload to ensure timely completion of projects, accommodating multiple and changing priorities.

 

 

- In collaboration with supervisor, sets

 

- Determines individual work priorities

 

- Optimizes time and resources efficiently, and

 

 

and acts on priorities for work activities

 

based on organizational needs and

 

anticipates unexpected situations in order to

 

 

which usually results in meeting

 

acts on those priorities with minimal

 

attain the highest quality work.

 

 

 

predetermined deadlines.

 

supervisory guidance; completes

 

- Clearly and independently recognizes how the

 

 

- Seeks assistance in managing

 

assignments on time.

 

work of the individual relates to work of others

 

 

multiple work assignments and in

 

- Sets realistic deadlines, based on

 

within and outside the organization;

understands

 

 

identifying priority assignments.

 

sound criteria; keeps supervisor and

 

the purpose of the work; and establishes

 

 

 

 

others informed of progress of

 

realistic priorities and deadlines.

 

 

 

 

 

activities.

 

- Develops project or work plans that set clear,

 

 

 

 

- Met written performance goals for

 

well-defined desired outcomes and establishes

 

 

 

 

last year as agreed upon with

 

methods of measuring progress, resulting in the

 

 

 

 

supervisor.

 

advancement of the organization’s mission.

 

6. Professional Competencies - Demonstrates knowledge, skills, and abilities to function successfully in the position.

 

 

 

 

 

 

 

 

 

 

 

 

- Basic knowledge of subject matter

 

- Demonstrates in depth knowledge

 

- Exhibits great depth and breadth of knowledge

 

 

required for assigned duties;

 

of subjects required by assigned

 

of multiple subjects; is viewed by others within

 

 

demonstrates average ability to learn

 

duties; is viewed as a competent and

 

and outside immediate office as a subject

 

 

and apply specialized knowledge.

 

credible authority on specialty or

 

matter expert.

 

 

 

- Seeks assistance in understanding

 

operational issues.

 

- Excellent grasp of complex issues, concepts

 

 

 

 

and situations, and applies lessons learned to

 

 

issues, concepts, and situations which

 

- Clear understanding of issues,

 

 

 

 

concepts and situations and applies

 

improve individual and organizational

 

 

affect job performance.

 

 

 

 

 

lessons learned to improve individual

 

productivity.

 

 

 

- Needs supervisory assistance to

 

 

 

 

 

 

productivity.

 

- Consistently produces work of exceptional

 

 

ensure quality work products.

 

 

 

 

 

- Quality of work is commensurate

 

quality.

 

 

 

 

 

 

 

 

 

 

 

with Officer’s rank.

 

 

 

 

7. Analysis, Judgment and Decision-Making - Identifies and considers information in order to reach sound conclusions and take appropriate actions.

 

- Needs guidance in analyzing facts,

 

- Employs sound judgment, logical

 

- Keen analytical insight and understanding of

 

 

alternatives, and impact before making

 

reasoning, and uses resources

 

key issues and relevant information to make

 

 

decisions.

 

wisely; makes timely and accurate

 

appropriate decisions; is sought after to resolve

 

 

- Majority of judgments are relevant and

 

decisions.

 

complex problems.

 

 

correct.

 

- Opinions sought by others.

 

- Consistent, superior judgment inspires the

 

 

 

 

 

 

confidence of others.

 

8. Overall Effectiveness - Synthesis of Officer’s performance, and impact on program in current position.

 

 

 

 

 

 

 

 

 

- An adequately performing Officer with

 

- A very competent Officer making

 

- A distinguished Officer, recognized for

 

 

some potential to accept increased

 

significant contributions that enhance

 

expertise with impact extending beyond

 

 

responsibilities and for professional

 

the assigned position, respected by

 

assigned position; serves as a role model for

 

 

growth.

 

peers; good potential for continued

 

others in the program.

 

 

 

 

growth and development.

 

 

 

 

 

 

 

 

 

 

Rater’s Comments. Comments are required. Describe the action(s) upon which you based your ratings. Explain the impact of the action and why it was important. (16 lines = 1280 Courier New 10pt. characters)

PHS-838 (Rev. 07/2010

Page 4 of 4

INSTRUCTIONS FOR COMPLETING PHS-838 (Rev. 12--07/10)

COMMISSIONED OFFICERS’ EFFECTIVENESS REPORT (COER)

Privacy Provisions

Personnel records are subject to the provisions of the Privacy Act of 1974. The applicable system of record is 09-40-0001, “PHS Commissioned Corps General Personnel Records,” HHS/PSC/HRS.

General Instructions

For additional information see Commissioned Corps Instruction 351.01 (CC25.1.1) of the Commissioned Corps Issuance System (CCIS), located on the Commissioned Corps Management Information System (CCMIS) web page: http://dcp.psc.gov.

For up-to-date deadlines and announcements consult the CCMIS and the Personnel Operations Memorandum (POM) (located on the CCMIS web page).

Raters and Reviewing Officials: Officers are responsible for ensuring that the Rater and Reviewing Official have all of the information needed to complete the COER by deadlines specified in the POM.

For assistance, contact your agency's Commissioned Corps Liaison Officer (A listing of agency Liaison Officers is located on the CCMIS web page). You may also contact the COER Administrator:

Office of Commissioned Corps Operations (OCCO)

ATTN: COER Administrator,

1101 Wootton Parkway, PL - 100,

Rockville MD 20852

e-mail: phscoers@hhs.gov

Put your PHS Serial Number (SERNO) in the space provided at the top, right of each page.

Use only the space available; additional pages will be discarded. The line and character limit for the text is included in each comment box. Note: spaces count as characters; returns count as lines.

Specific Instructions for Officer

1.Complete Section 1, Part I: Officer Administrative Information. All information is required.

a.Section 1, Part I.g, include all time in billet including time before any modifications to billet grade or description.

2.Complete Section 2: Officer's Comments.

a.All comments are optional, but strongly recommended.

b.In the spaces provided, describe your duties, goals and accomplishments during the period covered by the rating period(Section 1, Part I.b).

c.Provide a concise listing of your accomplishments in relation to performance elements that you will be rated on in Section 3.

d.In specific terms describe what you did and why it was important to your job duties, career goals or both.

3.Provide the completed form to your Rater by the deadline given in the POM.

a.Your Rater MUST have your Officer Administrative Information and Officer Comments to complete the evaluation.

i.If you need assistance identifying a Rater, consult the references above, or contact your agency Commissioned Corps Liaison Officer.

4.After your Rater shares his/her evaluation with you, you may make changes to Section 2: Officers Comments.

a.Any changes must be presented to the Rater for consideration.

b.The Rater may change his/her evaluation during this phase as well, but must present the revised evaluation to you prior to your concurrence/non-concurrence.

c.Consult the references above for additional details.

Additional instructions on next page

PHS-838 (Rev. 07/2010)

Instruction Page 1

5.Complete Section 1, Part III.

a.Indicate if you concur or disagree with the evaluation.

b.Sign and date the form in the space provided.

6.Provide the completed form to your Reviewing Official. If you need assistance, contact your Rater or your agency Commissioned Corps Liaison Officer.

Specific Instructions for Rater

1.Review Section 1, Part I: Officer Administrative Data. Contact the Officer to correct any inaccuracies.

2.Review Section 2: Officer's Comments.

3.Complete Section 3: Performance Evaluation. Optional if the period of supervision is less than 6 months.

4.Rate the Officer in relation to the needs of the position as follows:

a.1 Unsatisfactory range

b.2 - 3 Adequate range

c.4 - 5 Effective range,

d.6 - 7 Exceptional range

5.Fill in only one circle per element. To assist you, guidance for adequate, effective and exceptional performance is provided under ratings 2, 4 and 6.

a.Numbered ratings without narrative guidance are to be used when the officer is performing above or below ratings 2, 4 or 6.

i.For example, a score of 5 is appropriate when an officer performs above a level 4 description, but not as high as a level 6 description.

6.Rater's Comments at the end of Section 3 are required unless the Period of Supervision is less than 6 months.

a.Describe the action(s) upon which you base your ratings.

b.Be specific so that there is a clear connection between the Officer's action(s) and your rating.

7.Complete Section 1, Part II: Rater's Comments and Signature. Completion of all boxes is required unless otherwise indicated.

a.Provide your name and job title.

b.Provide your phone number and the Area Code. Outside of the U.S., include the Country Code.

c.Enter the amount of time supervising the Officer in years and months.

d.Rate the Officer's overall job performance during the Rating period.

e.List Strengths (Optional, but strongly encouraged).

f.List Areas for Improvement (Optional, but strongly encouraged).

8.Share your evaluation with the Officer and discuss performance. You may change the performance evaluation if you judge it necessary following your discussion with the Officer.

9.Once the evaluation is in final form, sign and date it in the space provided in Section 1, Part II.g.

10.Provide the completed form to the Officer.

Additional instructions on next page

PHS-838 (Rev. 07/2010)

Instruction Page 2

Specific Instructions for Reviewing Official

1.The Officer forwards the signed evaluation to you, the Reviewing Official.

2.The Reviewing Official completes Part IV, Reviewing Official's Comments, Signature, and Concurrence/Non- Concurrence.

a.Provide your name and job title.

b.Provide your phone number including the Area Code. Outside of the U.S., include the Country Code.

c.Review all sections for fairness and clarity.

3.Consider the following when reviewing the evaluation:

a.Are the ratings in Section 3 clearly supported by written comments on performance elements, strengths and/or areas for improvement?

b.Are the assigned scores for each competency supported by the Officer's comments?

c.Do the Rater's comments give an accurate description of the Officer and clearly support the assigned score?

d.Was the Rater sensitive to the Officer's grade and to any unique and significant differences in the assignment?

4.Note: If you are not satisfied that the ratings are well-justified, you may inform your agency Commissioned Corps Liaison Officer of your concerns.

a.If you agree with the evaluation you may indicate it on the form and sign, or provide comments (Optional, but strongly encouraged).

b.If you disagree with the evaluation, enter comments, otherwise optional.

c.Sign and date the evaluation.

After completing all sections of this form mail it to your agency Commissioned Corps Liaison Officer (A listing of agency Liaison Officers is located on the CCMIS web page).

PHS-838 (Rev. 07/2010)

Instruction Page 3

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RATER conclusion process described (stage 1)

2. The subsequent stage is to complete all of the following blank fields: g Signature Date, PART III RATED OFFICERS SIGNATURE, a Select one option, I concur with this raters, b Signature Date, I have read this review and have, I disagree with this evaluation, PART IV REVIEWING OFFICIALS, a Name and Job Title of Reviewing, b Phone Number, c Select one option, I concur with this evaluation, Although this evaluation is, Although this evaluation is, and d Reviewing Officials Comments.

Tips on how to complete RATER stage 2

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RATER conclusion process outlined (part 3)

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Filling in segment 4 in RATER

5. The final point to finalize this document is essential. Ensure you fill in the necessary form fields, like Leadership Demonstrates and, Demonstrates behavior that, Demonstrates behavior that, Consistently demonstrates, Initiative and Growth Recognizes, Needs assistance in identifying, Recognizes opportunities for, Independently seeks out and, Communication Skills Conveys, Needs assistance in expressing, Tailors communication verbal and, and Organizes and expresses complex, prior to finalizing. If you don't, it could lead to a flawed and probably incorrect paper!

Stage # 5 for completing RATER

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