Department Of Health And Human Services
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Department of Health and Human Services Work Plan
Division/Institution
Section/Unit
Employee's Name:
Position:
Supervisor's Name:
Position:
Appraisal is for period of: Date of Interim Review Discussion:
to
Date of Performance Planning Discussion: Date of Performance Appraisal Discussion:
Provide photocopies of signed form to Employee, Manager, and the Personnel Office
Performance Management Work Plan Employee's Signature
Key Responsibilities/ Results
Date
Supervisor's Signature
Result Expectations
Date
Tracking Source/ Frequency
Manager's Signature
Date
Actual Results
Combined KRR Rating Rating
Comments
Performance Management Work Plan Employee's Signature
Dimensions
Date
Supervisor's Signature
Behavioral Expectations
Date
Tracking Source/ Frequency
Manager's Signature
Date
Actual Results
Combined Dimensions Rating Rating
Comments
Improvement Plan
Development Plan
Interim Review
A. Knowledge, Skills and Abilities:
Mid-cycle
Special
Strengths/Weaknesses:
B. Training and Education:
Supervisor's Responsibilities:
Employee's Responsibilities:
Supervisor's Comments:
Employee's Comments:
Employee's Signature
Supervisor's Signature Date
Manager's Signature Date
Employee's Signature: Date
Supervisor's Signature Date
Manager's Signature Date
Date
Overall Performance Summary Rating: Please summarize employee's overall job performance based on information for each expectation:
Supervisor's Comments:
Employee's Comments:
Performance Pay Dispute Process: An employee may dispute the fairness of an annual overall summary rating of less than Outstanding by filing a complaint on DHHS Form PRD-1, which must be received by the division/institution personnel manager within 15 calendar days from the date the employee receives his/her copy of the work plan and overall summary rating. Performance reviews other than the annual review are not appealable under the DHHS Performance Rating Dispute Process. Copies of the Dispute Process (DHHS Directive Number III-9) and DHHS Form PRD-1 are available from all DHHS Human Resources offices.
Employee's Signature:
Supervisor's Signature:
Date
Manager's Signature
Date
Date
Division/Institution
Section/Unit
Employee's Name:
Position:
Supervisor's Name:
Position:
Appraisal is for period of: Date of Interim Review Discussion:
to
Date of Performance Planning Discussion: Date of Performance Appraisal Discussion:
Provide photocopies of signed form to Employee, Manager, and the Personnel Office
Performance Management Work Plan Employee's Signature
Key Responsibilities/ Results
Date
Supervisor's Signature
Result Expectations
Date
Tracking Source/ Frequency
Manager's Signature
Date
Actual Results
Combined KRR Rating Rating
Comments
Performance Management Work Plan Employee's Signature
Dimensions
Date
Supervisor's Signature
Behavioral Expectations
Date
Tracking Source/ Frequency
Manager's Signature
Date
Actual Results
Combined Dimensions Rating Rating
Comments
Improvement Plan
Development Plan
Interim Review
A. Knowledge, Skills and Abilities:
Mid-cycle
Special
Strengths/Weaknesses:
B. Training and Education:
Supervisor's Responsibilities:
Employee's Responsibilities:
Supervisor's Comments:
Employee's Comments:
Employee's Signature
Supervisor's Signature Date
Manager's Signature Date
Employee's Signature: Date
Supervisor's Signature Date
Manager's Signature Date
Date
Overall Performance Summary Rating: Please summarize employee's overall job performance based on information for each expectation:
Supervisor's Comments:
Employee's Comments:
Performance Pay Dispute Process: An employee may dispute the fairness of an annual overall summary rating of less than Outstanding by filing a complaint on DHHS Form PRD-1, which must be received by the division/institution personnel manager within 15 calendar days from the date the employee receives his/her copy of the work plan and overall summary rating. Performance reviews other than the annual review are not appealable under the DHHS Performance Rating Dispute Process. Copies of the Dispute Process (DHHS Directive Number III-9) and DHHS Form PRD-1 are available from all DHHS Human Resources offices.
Employee's Signature:
Supervisor's Signature:
Date
Manager's Signature
Date
Date
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