2012 STAFF PERFORMANCE ASSESSMENT FORM
Employee Name Time in Job
Job Title Date: / /
Assessment Period / / to / /
Provide a qualitative assessment of your employee’s performance. Also assess the employee’s progress in
meeting last year’s goals. Please limit your narrative to one page.
List your employee’s goals for the upcoming year. Include a due date for each goal.
Merit Adjustment Recommendation
Managers may recommend a modest merit pay increase for the employee based on his or her documented
performance. Will this employee receive a merit increase?
Yes No Please explain:
A signature is required only to indicate that you, the employee, have discussed this evaluation with your
supervisor. Signing this document does not denote agreement.
Employee’s Signature_____________________________________________ Date ________________
Completed by___________________________________________________ Date _________________
Department Head________________________________________________ Date _________________