UCD Health System
MSP EMPLOYEE PERFORMANCE APPRAISAL REPORT
This form is used to evaluate the performance of Managers and Senior Professional staff. Examples of
well-written evaluations and summaries of accomplishments are on the Web at
http://www.hr.ucdavis.edu/Forms/All/Perf_Eval.
Review Cycle: _________
Employee name
Employee number
Title code and payroll title
Percent appointment
Working title (optional)
Department
Account / Cost Center
Length of time in this position
Supervised for entire review period?
Yes
No
(months:
)
JOB-RELATED PERFORMANCE: Describe performance during the review period. The evaluation must
be based on clearly-defined job functions or performance expectations. Include an evaluation of the
employee’s professionalism and their ability to encourage others to act in a professional manner. The
rating in the Supervisor's Recommendation must be supported by the narrative. Use additional sheets if
needed.
This employee completed their annual safety training (including personal safety, electrical safety, fire
safety, infection control, injury prevention and occupational safety) on _________.
SUPERVISOR’S RECOMMENDATION:
I rate
‘s performance for this review period as:
Exceeds Expectations
Meets Expectations
Does Not Meet Expectations
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UCD Health System
MSP EMPLOYEE PERFORMANCE APPRAISAL REPORT
Employee Name
Please appraise the employee’s ability in the following areas:
Communication skills:
Ability to work in a diverse environment:
Efforts in transforming their areas of responsibility toward excellence:
PATIENT ASSESSMENT: Complete this section only for employees or those with staff who have
responsibility for human patient assessment, treatment or care.
Please check the age group(s) served and address the success with which the individual produces the
expected results of clinical interventions.
Infants (0-12 months)
Children (12 months - 15 1/2 years)
Adolescents (9-18 years)
Adults (18 years - 64 years)
Geriatrics (65 years and older)
Please appraise the employee’s (and/or their staff’s) ability to assess, treat, or care for patients, taking
into account the patient’s cultural background, spiritual beliefs, disease process or diagnosis and
functional status. Include in the appraisal, the employee’s (and/or their staff’s) ability to ensure that
patients receive effective, understandable, and respectful care that is provided in a manner compatible
with their cultural health beliefs, practices, and preferred language.
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UCD Health System
MSP EMPLOYEE PERFORMANCE APPRAISAL REPORT
Employee Name
SUPERVISORS AND MANAGERS: Each supervisor and manager must be evaluated on supervisory
performance, support of the Principles of Community (including equal employment opportunity and
affirmative action performance), and the safety record of the unit supervised.
FUTURE GOALS OR PERFORMANCE EXPECTATIONS:
SIGNATURES
Employee: I have read and received a copy of this evaluation.
Date
Supervisor: This is my evaluation of the employee's performance during the review period.
Date
Department Head / Chairperson: I concur with this evaluation.
Date
DEPARTMENT HEAD COMMENTS: (optional)
EMPLOYEE COMMENTS: (optional)
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UCD Health System
MSP EMPLOYEE PERFORMANCE APPRAISAL REPORT
EMPLOYEE SUMMARY OF ACCOMPLISHMENTS
Period covered (month/day/year): from ________ to ________
Employee Name
Department
This provides an opportunity to reflect upon actual work and ensure good communication between
employee and supervisor. Use of this form is optional, but may be required by a dean, vice chancellor, or
department. Examples of well-written summaries of accomplishments are on the Web at
http://www.hr.ucdavis.edu/Forms. Use this form (with additional sheets if needed) to describe:
1.
2.
3.
4.
5.
accomplishments related to each job function
accomplishments related to established goals and/or performance expectations
future goals and/or performance expectations
training and development needs, if any
support of the Principles of Community (including equal employment opportunity and affirmative
action performance and job-related commitment to good interpersonal relations).
6. Demonstrated role model behavior in professionalism, excellent communication and transforming
work products and staff accomplishments to a high level of performance.
X3
Employee Signature
Date
4