THE TWELVE INC.
MULTI SOURCE FEEDBACK FORM
NOTE: This form is intended as information only. As such, it is for internal use only and is not
to be mailed or presented to customers / co-workers in any way.
Employee _______________________________________ Position ______________________
Supervisor ______________________________________ Date _________________________
Feedback
Requested From _____________________________________________
_____ Co-Worker
_____ Referral Agency Representative
Position ___________________________ Telephone _______________________
Supervisor _________________________________________
I would like to ask you for some candid feedback on _________________________ performance
during this past year. My questions are relatively brief and it should only take a few minutes.
I'm asking for your input so that I can develop a more well-rounded assessment of this employee's
performance. I will be asking several individuals (peers, customers, and/or managers) for their
input and then incorporating the overall results into the employee's annual performance review.
Please be as candid and objective as possible. Individual results will be kept completely
anonymous and will only be included in the review in summary fashion.
1. Overall Satisfaction
What is your overall level of satisfaction with his/her ability to meet your needs? Please provide
specific examples?
2. Special Projects / Contributions
In addition to his/her usual responsibilities in the past year, what special project(s) has
he/she worked on that you are aware of that have required considerable additional effort? What
specific contribution(s) did this employee make to the project's success?
3. Performance/Service Enhancements
What specific services, support, reports, projects, etc. would you like to receive from or
work on with this employee and/or department during the next year? What skills or
knowledge, if improved or developed, would help this employee become more effective in meeting
your needs or in his/her general interactions with you?
THANK YOU FOR TAKING THE TIME TO ANSWER MY QUESTIONS. THIS WILL HELP
TO PROVIDE A MORE WELL ROUNDED EVALUATION OF __________________.
NOTE: This information is to remain confidential and should only be included in
the review in summary fashion. Specific comments or assessments made by this respondent
should not be shared directly with the employee.
This form is to be kept in the Supervisor’s file only.