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Staff Performance Appraisal Form Page 3
Staff Performance Appraisal Form
Distribution: Original – Human Resources Copy – Supervisor Copy - Employee
Page Two
PERFORMANCE APPPRAISAL FORM
RATER’S OVERALL COMMENTS:
SECOND LEVEL SUPERVISOR’S COMMENTS: (Optional)
EMPLOYEE’S COMMENTS (Use attachments, if necessary):
EMPLOYEE’S SIGNATURE: _____________________________________________ DATE: _____________________
Signature does not imply concurrence with rater’s appraisal, only that appraisal was administered.
RATER’S NAME: _______________________________________________________
RATER’S SIGNATURE: __________________________________________________ DATE: _____________________
SECOND-LEVEL SUPERVISOR’S NAME: ______________________________________________________________
SECOND-LEVEL SUPERVISOR’S SIGNATURE: ____________________________ DATE: _____________________
EMPLOYEE’S REFUSAL TO SIGN: I certify that this performance appraisal was discussed with the employee who
refused to sign it.
RATER’S CERTIFICATION: ______________________________________________ DATE: ____________________
*Please deliver form to the Division of Human Resources, Payroll Department, PC 220.
PLEASE PRINT
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Revised 10/15/200
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