Revised 7/11
Annual Performance Evaluation Classified Staff
Employee/Position Identification Information
Employee Name:
Employee State ID Number:
Agency Name & Code:
Position Number:
Northern Virginia Community College (280)
Department/Division:
Campus (check the appropriate location):
Evaluation Cycle:
AL
AN
CS
ELI
Supervisor Name (print):
LO
MA
MEC
WO
October 25, 20__ – October 24, 20__
Core Responsibilities
Evaluation
Review the Position Description and
evaluate in order of importance
Provide specific behavioral-based feedback comments on strengths and areas for improvement/Development
Extraordinary Contributor
Contributor
Comments on Results Achieved/Strengths
Below Contributor
Areas for Improvement/Development
1
Extraordinary Contributor
Contributor
Comments on Results Achieved/Strengths
Below Contributor
Areas for Improvement/Development
2
Extraordinary Contributor
Comments on Results Achieved/Strengths
Contributor
Below Contributor
Areas for Improvement/Development
3
Page 1 of 5
Extraordinary Contributor
Contributor
Comments on Results Achieved/Strengths
Below Contributor
Areas for Improvement/Development
4
Extraordinary Contributor
Contributor
Comments on Results Achieved/Strengths
Below Contributor
Areas for Improvement/Development
5
Extraordinary Contributor
Contributor
Comments on Results Achieved/Strengths
Below Contributor
Areas for Improvement/Development
6
Evaluation
Special Assignments
Provide specific behavioral-based feedback comments on strengths and areas for improvement/Development
Extraordinary Contributor
Contributor
Comments on Results Achieved/Strengths
Agency/Departmental
Objectives
Below Contributor
Areas for Improvement/Development
Evaluation
Provide specific behavioral-based feedback comments on strengths and areas for improvement/Development
Extraordinary Contributor
Comments on Results Achieved/Strengths
Contributor
Below Contributor
Areas for Improvement/Development
Page 2 of 5
Additional Comments
List other significant results for the performance cycle, including year-end learning accomplishments.
Next Year’s Development Plan
List recommended training and development activities related to the work tasks and duties, any learning goals identified by the
employee and/or supervisor, and actions needed to accomplish the learning goals and professional developmental needs.
Overall Results Assessment and Rating Earned
An employee receiving an overall rating of "Below Contributor" must have received at least one Notice of
Improvement Needed/Substandard Performance or Written Notice during the performance cycle.
An employee who earns an overall rating of “Below Contributor” must be evaluated again within three
months.
An employee receiving an overall rating of "Extraordinary Contributor" must have received at least one
Acknowledgment of Extraordinary Contribution form during the performance cycle (attach form to the
evaluation). However, the receipt of an Acknowledgment of Extraordinary Contribution form does not
guarantee an overall performance rating of “Extraordinary Contributor” for that performance cycle.
Overall Rating Earned
Extraordinary Contributor
Contributor
Below Contributor
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Review of Performance Evaluation
Sign below to acknowledge that the document has been reviewed. Supervisor, reviewer, and employee sign in the order indicated
below. Once signed by all parties, send the evaluation to Employee Relations, Human Resources Department, to be placed in the
employee’s personnel file (submit via interoffice mail or electronically via e-mail). Retain a copy of the signed document for
supervisory records and provide a signed copy to the employee.
Supervisor’s Comments:
Signature:
Date:
Print Name:
Reviewer’s Comments:
Signature:
Date:
Print Name:
Employee’s Comments:
Signature:
Date:
Print Name:
Page 4 of 5
EMPLOYEE WORK PROFILE
AGENCY OPTIONAL SECTIONS
Confidentiality Statement:
I acknowledge and understand that I may have access to confidential information regarding [employees,
students, patients, inmates, the public]. In addition, I acknowledge and understand that I may have access
to proprietary or other confidential information business information belonging to NVCC. Therefore, except
as required by law, I agree that I will not:

Access data that is unrelated to my job duties at NVCC.

Disclose to any other person, or allow any other person access to, any information related to NVCC that
is proprietary or confidential and/or pertains to [employees, students, patients, inmates, the public].
Disclosure of information includes, but is not limited to, verbal discussions, FAX transmissions,
electronic mail messages, voice mail communication, written documentation, “loaning” computer access
codes, and/or another transmission or sharing of data.
I understand that NVCC and its [employees, students, patients, inmates, public], staff or others may suffer
irreparable harm by disclosure of proprietary or confidential information and that NVCC may seek legal
remedies available to it should such disclosure occur. Further, I understand that violations of this
agreement may result in disciplinary action, up to and including, my termination of employment.
______________________________________________ ___________________________
Employee Signature
Date
Annual Requirements:
Activity
Required In-Service or other training
Valid Licensure/Certification/Registration
Employee Health Update
Current? If so, date completed?
Yes _____________Date
Yes _____________Date
Yes _____________Date
No
No
No
N/A
N/A
N/A
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