Mount Carmel HealthProviders, Inc.
Employee Appraisal Form
Employee’s Name ______________________________________________________________ Cost Center __________________________________
Job Title ______________________________________________________________________ Location _____________________________________
Appraisal Date: From __________________________ to _____________________________ Hire Date ____________________________________
1 2 3 4 5
Far Below Standard Below Standard Meets Standard Above Standard Well Above Standard
I. PRODUCTIVITY – Observable results or measurable output as related to the specific job duties.
A. Quality
Many errors and mistakes Work in some respects below Work quality consistently Results virtually perfect;
Often produces work of
work incomplete. Quality too quality standards. Work acceptable; requires some exceptional accuracy,
satisfactory high quality;
poor to retain employee in job requires frequent direction. direction. thoroughness, and
requires minimum direction.
without improvement effectiveness. Can work
without direction.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
B. Quantity
Amount of work Irregular in meeting standard Consistently produces a Often produces a volume that Consistently exceed job
accomplished totally requirements and/or volume of work that meets job exceeds standard requirements. requirements; exceptional
inadequate, far below the productivity below standard. requirements. speed and volume of work
standard to retain employee in accomplished.
the job.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
C. Initiative
A slow starter; requires some
Does only what is directed: Consistently a self-starter; Often suggests better ways Consistently makes
direction to accomplish work;
distracted on the job; is not a helps others and makes for accomplishing work. Does suggestions for improving
self-starter. seldom goes out of way to suggestions for improvement in additional work without work efficiency and quality;
perform other duties. work methods. direction. resourceful in new situations.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
D. Adaptability
Extremely slow to adjust to Shows some willingness to Consistently demonstrates a Often identifies situations Consistently identifies
changes in job assignments. change from normal job duties willingness to accept changes that require changes in work situations that require changes
but with some reluctance. in job duty assignments, to patterns and responds in work patterns and responds
accept new ideas, and to try appropriately. appropriately and in a timely
new methods. manner.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
E. Safety/Sanitation
Violates safety, sanitation Requires periodic Practices safety, sanitation Identifies ways to make work
Corrects safety, sanitation,
and housekeeping policies instructions about safety, and housekeeping policies. more safe, sanitary and orderly.
and housekeeping conditions to
frequently. sanitation and housekeeping Call violations to the attention Encourages others to practice
best of ability.
policies. of the immediate supervisor. good safety and sanitation
habits.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
II. JOB KNOWLEDGE AND SKILLS – Understanding of and ability to perform job duties.
A. Learning
Very slow to learn new job Does not learn new tasks in Learns new tasks in timely Learns new tasks quickly Consistently learns new tasks
tasks, requires constant timely manner; requires and demonstrates proficiency. with minimal instruction. independently without formal
instruction. frequent instruction. instruction.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
B. Teaching Others
January 1, 2004
Unable to communicate and Demonstrates some difficultyInstructs Others effectively Often instructs others when Routinely recognizes need
demonstrates job tasks to instructing others. when asked; is able to needed without being asked. for instruction of others.
others. communicate and demonstrate Teaches in highly effective
job tasks. manner/
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
C. Application of Knowledge & Skills
Does not apply knowledge Needs assistance in Applies skills and knowledge Informed about significant Seeks additional job
and skills as required by job application of knowledge and of the techniques, processes, job-related activities; functions knowledge and skills and
standard. skills to meet job standards procedures, equipment and with minimal supervision. creatively applies to overall
materials to do job properly. improvement of center
functions.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
III. ATTITUDE AND BEHAVIOR – Demonstrated cooperativeness and support of Center and Network policies and procedures.
A. Policies and Procedures
Does not follow center and Demonstrates support by Verbalizes support of center
network policies and conforming to center and and network policies and
procedures. network policies and procedures to co-workers.
procedures. Use appropriate
channels to inquire about or
express dissatisfaction with
policies and procedures.
EXAMPLES REQUIRED on ratings of 1 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
B. Verbal & Written Communications
Verbal and written Verbal and written Verbal and written Verbal and written Verbal and written
communications are usually communications are sometimes communications are clear. communications are very clear. communications are precise,
unclear and/or confusing. unclear and confusing. Manner Manner is polite and Checks own communication to pleasant, and supportive.
Manner is rude. Uses socially is abrupt and insensitive – lacks considerate. Uses socially determine if others understand. Demonstrates exceptional skill
unacceptable language. tact at times. acceptable language. in dealing with others.
Communication is consistent
with needs of listener.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
C. Appearance and Dress Code
Many violations of center Wears Clothing consistent Projects and exceptional
dress code. Personal hygiene with dress code. Personal image.
needs attention. Must hygiene is attended to.
constantly be reminded to wear Appearance is clean and well
nametag. groomed. Wears name tag
EXAMPLES REQUIRED on ratings of 1 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
IV. ATTENDANCE – Extent to which employee can be depended upon to be at work when scheduled.
Usually late or absent. Frequently late or absent, Attendance meets standard. Seldom absent or late. Perfect attendance; always on
Rarely, if ever, notifies Seldom notifies supervisor of Reports absence or tardiness in Exceeds standard. time. Always uses time card
supervisor of absence or absence or tardiness in advance. At workstation on and always returns from lunch
tardiness in advance. Often advance. Sometimes time. Able to get to work periods promptly. Always
asks for time off. Seldom responsive to all-in. regardless of adverse weather responsive to call-ins.
responsive to call-in. of other personal problems.
Responsive to call-in.
Unscheduled PTO/Days _______________ Incidents of leaving early _______________
Unpaid time off/days __________________ Being Late ________________
Total __________________
V. RELIABILITY – Demonstrates qualities that merit confidence and trust in performance of job duties.
A. Judgement
Makes decisions without Often acts in haste without Generally demonstrates Makes appropriate Displays exceptional ability
basis. Neglects to take using available information of logical thinking by making recommendations for the to analyze and deal with
appropriate action. Does not delays appropriate action when sound decisions after solution to problems. Rarely situations that otherwise could
make use of available sufficient information is considering available facts; requires assistance. be potential problems
information. Does not ask for available. Sometimes fails to seeks additional data on which
assistance when needed. ask for needed assistance. to base decisions. Consistently
Decisions sometimes based on take appropriate action.
emotions.
EXAMPLES REQUIRED on ratings of 1,2, 4 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
January 1, 2004
B. Confidentiality
Shares confidential Consistently demonstrates High regard for confidential
information with unauthorized the ability to recognize information. Always knows
individuals. confidential information and what information to share and
who should have access to it. can identify who should have
Discloses information only to it. Encourages others to respect
authorized individuals. patient confidentiality. Assists
others in identifying
confidential information.
EXAMPLES REQUIRED on ratings of 1 & 5 _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
COMPLETE THIS BLOCK FOR PROBATIONARY PERIOD
EVALUATION OF PROBATIONARY PERIOD PERFOMANCE – Considering the employee’s length of time on job, how do you evaluate performance so far?
Progress too slow to retain on job if improvement is not made. (see no. 3 under “Appraisal Summary”)
Progressing, but not up to expectations. (see no. 3 under “Appraisal Summary”)
Making acceptable progress toward meeting job standards.
Progressing rapidly.
Progressing at an exceptional rate.
Estimated time required to learn this job: _________ months
Employee’s time on job: ________ months
APPRAISAL SUMMARY
1. Supervisor’s comments on employee potential (including whether or not the employee is suited to type of work in this position). ________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
2. Explain how the employee’s overall performance has or has not improved since the last evaluation. ______________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
3. List specific areas in which employee needs to improve, how improvement will be accomplished, and what time limits have been established. ____________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
4. List specific goals for employee, how goals will be measured, and what time limits have been established.(exempt employees only) ____________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
OVERALL RATING
Far Below Standard (1 through 1.4) = 0% Above standard(3.5 through4.4) = 3.0%
Below Standard(1.5 through 2.4) = 0.0% Meets Standard(2.5 through 3.4) = 2.0% Well Above Standard(4.5 through 5.0) = 4.0%
Raters Comments:
Signature of Rater _________________________________________________ Date _______________________________
Employee Comments:
Signature of Employee_____________________________________________ Date _______________________________
January 1, 2004