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!

Form NameForm Phs 838
Form Length7 pages
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesCCMIS, phs 838 form, PHS-838, phs 838

Form Preview Example

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

Officer’s SERNO

Commissioned Officers’ Effectiveness Report


































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

b. Period Covered by Report












From ______________________

To ______________________















c. Type of Report

(Check only one):


Officer Transfer

Supervisor Transfer


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








































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.












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



















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.

























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 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







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









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








problem and contributes to the solution,



success of individual and group








enhancing the successful outcome of












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







- 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


























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












- 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.







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





resolution of conflicts or




the work environment. Serves as mediator in








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;




identifying priority assignments.


sound criteria; keeps supervisor and


the purpose of the work; and establishes





others informed of progress of


realistic priorities and deadlines.








- 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







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






- Needs supervisory assistance to









- Consistently produces work of exceptional



ensure quality work products.






- Quality of work is commensurate














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





wisely; makes timely and accurate


appropriate decisions; is sought after to resolve



- Majority of judgments are relevant and




complex problems.





- 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





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



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:

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


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)

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RATER conclusion process outlined (part 3)

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