CMS PLANNING AND EVALUATION FORM
4117.32D Exceptional Children Supervisory
EMPLOYEE DATA
Employee Name School or Department
Exceptional Children
Employee Identification Number Job Title
DIRECTIONS: OVERALL RATING
All employees should be rated on all Core Values and Balanced Scorecard Competencies.
Deselect any FUNCTIONAL COMPETENCY that is not applicable to the position. All people in the same job title must be evaluated on the same competencies.
Rate (as described on page four) all selected competencies by entering an 'x' in one of the columns: Outstanding, Very Effective, etc..
Refer to the Competency Matrix for specific competency descriptions (or move your curser to the corner of the competency description for the comment box.)
The online form will automatically calculate the overall rating. YOU MUST RATE ALL COMPETENCIES SELECTED FOR AN ACCURATE CALCULATION.
To calculate manually, use the directions on page four and write the score in the Overall Rating box.
Supervisor comments should include goals achieved during the prior year. Employee comments are optional.
COMPETENCIES
Very Somewhat
Select Core Values Competency Descriptions Outstanding Effective Not Effective
Effective Effective
x Respect Treats people with dignity and respect, acknowledging unique qualities in
people.
x Mutual Support Assigns team responsibilities, addresses conflicts and provides support to
ensure a productive and collegial work environment.
x Trust Builds trusting relationships by demonstrating integrity and high ethical
standards.
x Effective Communicates accurate information in a clear and timely manner. Ensures key
Communication issues are addressed and that important information is provided quickly in an
effective manner.
x Achievement of Goals Sets own and direct report development goals that support team and
department goals. Holds self and others accountable for achievement of
development goals.
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CMS PLANNING AND EVALUATION FORM
4117.32D Exceptional Children Supervisory
Very Somewhat
Select Balanced Scorecard Competency Descriptions Outstanding Effective Not Effective
Effective Effective
x Customer Focus Trains and supports team to deliver quality services, measures customer
service satisfaction and pursues necessary improvement opportunities.
x HR Learning & Growth Establishes professional development goals for self and team. Shows planning
and initiative for achievement of goals.
x Business Process Monitors work results, works with staff to continually improve efficiency,
Focus effectiveness and quality.
x Financial Focus Maintains an awareness of the budget and considers cost-savings when
making plans, decisions and assigning staff.
Exceptional Children Very Somewhat
Select Functional Competency Descriptions Outstanding Effective Not Effective
Functional Effective Effective
x Detail Orientation Ability to analyze problems, identify alternate solutions, project consequences of
proposed actions and implement recommendations to support goals.
x Flexibility Works effectively according to priority while maintaining composure under the
pressure of deadlines and customer demands. Effectively handles demands
x Decision Making Makes and implements decisions effectively in accordance with established
rules and procedures.
x Planning and Creates and communicates workplans controlling time and resources
Organizing necessary for completion of assignments. Plans and coordinates programs for
the Exceptional Children Department.
x Conflict Management Assumes control of a conflict situation in a timely and self-assured manner,
while demonstrating a sense of authority.
x Document Processing Completes and reviews documentation for accuracy, completeness and
compliance with pertinent CMS and government policy.
x Education and Provides leadership on Exceptional Children curriculum and instruction issues
Treatment as well as compliance concerns. Assists in the formulation and modification of
educational programs.
x Computer Expertise Uses computer skills in an efficient manner to effectively complete and assign
work. Proficient with computer skills and CMS internal computer systems.
x Safety and Security Communicates safety and security risks, monitors compliance with safety and
security guideliens. Identifies and addresses staff training needs in areas of
safety and security.
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CMS PLANNING AND EVALUATION FORM
4117.32D Exceptional Children Supervisory
SUPERVISOR COMMENTS
EMPLOYEE COMMENTS
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CMS PLANNING AND EVALUATION FORM
4117.32D Exceptional Children Supervisory
INDIVIDUAL GROWTH PLAN (IGP)
Target
Development Goal Skill/Competency Being Developed Action Steps Success Measures Completion
Date
Goal #1
Goal #2
Goal #3
Goal #4 (Optional)
Date of next IGP checkpoint meeting (at 6-month intervals): (Month/Year)
SIGNATURES
Signature of this evaluation form indicates that both parties have reviewed and acknowledged the evaluation and the IGP together.
Employee Name Supervisor Name
Employee Signature Supervisor Signature
Date: Date
A copy of this document will be placed in your employee personnel file after five days.
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CMS PLANNING AND EVALUATION FORM
4117.32D Exceptional Children Supervisory
RATING SCALE
CALCULATING THE OVERALL RATING MANUALLY
Outstanding
If you are completing the form on-line the overall rating will be calculated automatically. The team member demonstrates the listed practices to a degree that is close to or the best
you have ever seen. Or, the team member consistently demonstrates the listed practices
If you are completing the form on paper, do the following to calculate the overall rating. and does yet other things that are above and beyond expectations. If all team members
performed at this level, the team would exceed goal targets. The message delivered when
rating someone Outstanding is that the only areas for growth would be to further expand
1) Calculate the total value of ratings using the formula below. on this obvious strength and find new ways to apply it to the benefit of the team and
CMS. Specific comments (i.e., evidence, explanation) are required for rating a
(# of competencies rated as Outstanding) * 4 competency Outstanding.
+ (# of competencies rated as Very Effective) * 3 Very Effective
+ (# of competencies rated as Effective) * 2
+ (# of competencies rated as Somewhat Effective) * 1 The team member consistently demonstrates the listed practices. If all team members
demonstrated practices at this level the team would meet all goal targets and likely
+ (# of competencies rated as Unsatisfactory) * 0 exceed some goal targets. The message delivered when rating someone Very Effective is
= that performance is completely satisfactory. The employee is a top performer in this area
of competence.
2) Calculate the overall, numeric rating score by dividing the
Effective
total value of ratings by the total number of competencies rated.
The team member demonstrates the listed practices most of the time. Performance in this
3) Look up the numeric rating in the table below and write the appropriate area is satisfactory and similar to that of others you have regarded as good performers. If
all team members demonstrated practices at this level, the team would make good
rating description on page one. progress toward and meet most of the goal targets. The message delivered when rating
someone Effective is that performance is satisfactory. There are still areas that require
Numeric Rating Overall Rating Description improvement in order to be considered an excellent performer in this area of competence,
but, overall, a job well done.
3.5 - 4.0 Outstanding Somewhat Effective
2.5 - 3.4 Very Effective
1.5 - 2.4 Effective The team member sometimes demonstrates the listed practices. If all employees
demonstrated performance at this level, the team would make progress toward its goals,
1.0 - 1.4 Somewhat Effective
but miss goal targets. The message delivered when rating someone Somewhat Effective
0 - .9 Not Effective is that the employee performs well at times but needs to do so more consistently. The
employee shows promise, but needs to improve in order to be considered a good
performer in this area of competence.
Not Effective
The team member rarely demonstrates the listed practices. Performance in this area is
close to or the worst you have ever seen. The message delivered when rating someone
Not Effective is that performance is unsatisfactory and the employee requires significant
improvement in this area. Specific comments (i.e., evidence, explanation) are required
when rating a competency Not Effective, as well as a formal Action Plan.
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