Performance Factors Rating Scale Supportive Details or Comments 1. Quality – The extent to which an employee’s O ■ 100-90 Points work is accurate, thorough and neat. V ■ 89-80 G ■ 79-70 I ■ 69-60 U ■ Below 60 2. Productivity – The extent to which an O ■ 100-90 Points employee produces a significant volume V ■ 89-80 of work efficiently in a specified period G ■ 79-70 of time. I ■ 69-60 U ■ Below 60 3. Job Knowledge – The extent to which O ■ 100-90 Points an employee possesses the practical/technical V ■ 89-80 knowledge required on the job. G ■ 79-70 I ■ 69-60 U ■ Below 60 4. Reliability – The extent to which an O ■ 100-90 Points employee can be relied upon regarding V ■ 89-80 task completion and follow-up. G ■ 79-70 I ■ 69-60 U ■ Below 60 5. Attendance – The extent to which an O ■ 100-90 Points employee is punctual, observes prescribed V ■ 89-80 work break/meal periods, and has an G ■ 79-70 acceptable overall attendance record. I ■ 69-60 U ■ Below 60 6. Independence – The extent to which an O ■ 100-90 Points employee performs work with little or V ■ 89-80 no supervision. G ■ 79-70 I ■ 69-60 U ■ Below 60 Please Print Employee Name__________________________________________ Title _____________________________________________ Department _____________________________________________ Employee Payroll #__________________________________ Reason for Review ■ Annual ■ Promotion ■ Peer Appraisal ■ Unsatisfactory Performance ■ Merit ■ End of Introductory Period ■ Other _________________________________ Date employee began present position _____________ Date of last appraisal______________ Scheduled appraisal date ____________ / / / / / / O – Outstanding – Performance is exceptional in all areas and is recognizable as being far superior to others. V – Very Good – Results clearly exceed most position requirements. Performance is of high quality and is achieved on a consistent basis. G – Good – Competent and dependable performance. Meets the performance standards of the job. I – Improvement Needed – Performance is deficient in certain areas. Improvement is necessary. U – Unsatisfactory – Results are generally unacceptable and require immediate improvement. No merit increase should be granted to individuals with this rating. N/A – Not Applicable or too soon to rate. Definitions of Performance Ratings Instructions: Carefully evaluate employee’s work performance in relation to the essential functions of the job. Check Rating box that indicates the employee’s performance. Indicate N/A if not applicable. Assign points for each Rating within the Scale and write that number in the corresponding Points box. Points will be totaled and averaged for an overall performance score. Performance Appraisal CD-ROM Routing ■ Payroll ■ ___________________ ■ ___________________ Effective Date of Change _____________ ■ New Hire ■ Change ■ Separation Employee Name _____________________________________________________________________________________________ Social Security #_____________________________ Employee/Payroll # ____________ Dept. _____________________________ Address ____________________________________________________________________________________________________ Telephone # _______________________________ Date of Birth (for administrative use only) __________________ Status: ■ Full-Time ■ Part-Time ■ Full-Time Temporary ■ Part-Time Temporary ■ Other______________________ Job Title_______________________________ ■ Exempt ■ Non-Exempt ■ Hourly W-4 Attached? ■ Yes ■ No / / Last First Middle ( ) Street City State ZIP Code / / Employee Signature (Optional) _________________________________________________________________________ Date ________________ Supervisor/Designated Manager Signature _____________________________________________________________ Date ________________ Human Resources/Payroll Manager Signature ___________________________________________________________ Date ________________ Name and Title Name and Title Additional Comments ________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ / / / / / / Name and Title Please Print Separation Separation Date _________________ Last Day Worked _________________ Last Day Paid _______________ Voluntary Separation Involuntary Separation Notice of COBRA Rights Provided on _____________ Election of COBRA Yes No Start Date of Coverage _______________ If yes, describe type of coverage elected: _____________________________________________________________________________ Leave of Absence Begin Leave ______________ Return from Leave ________________ Educational Personal Family/Medical Leave (Including Pregnancy) Short-Term Disability Long-Term Disability Other ______________________________ Payroll/Status Change Notice Type From To Comments _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ■ Address Change ■ Demotion ■ Department ■ FLSA Reclassification ■ 401(k)/403(b) Contribution ■ Insurance Eligibility ■ Job Title ■ Change of Insurance ■ Layoff ■ Length of Service Increase ■ Merit Increase ■ End of Introductory Period ■ Promotion ■ Reevaluation of Current Job ■ Rehire ■ Resignation ■ Retirement ■ Salary/Wage ■ Separation ■ Shift Change ■ Transfer ■ Union Scale ■ Other ______________ / / / / / / / / / / / / / / Change(s) for Current Employee This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have. Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties. ©2016 ComplyRight, Inc. A2168 Two easy ways to reorder: hrdirect.com • 800-999-9111 7 Recordkeeping Forms Payroll Status Change Notice, 3-Part Easily tracks personnel changes – from new addresses to salary increases – and includes separate sections for recording the details surrounding a leave of absence or separation. • Helps ensure changes are properly processed • Features ComplyRight tips for optimal, compliant use • Also available in small format Description Item # Payroll Status Change Notice 3-Part, 50 Pack A2168 Employee Performance Appraisal Form Easily evaluates employee performance that addresses 11 key performance categories, such as productivity, job knowledge and creativity. This form creates a consistent, timesaving review process. • Performance appraisals provide the documentation you need to justify promotions and can protect your company against potential termination disputes • Helps you communicate your expectations clearly and provides employees with a tangible way to gauge their progress Description Item # Employee Performance Appraisal, 50 Pack A2192 Consecutive Employee Warning Report, 4-Part This four-part carbonless form reduces the time, effort and paperwork required to document problems and follow up with employees. The all-in-one form includes three detachable written warning slips to issue to the employee, along with a back page that captures the dates and content of each warning for your files. • Captures all the necessary details for documenting repeat offenses • Eliminates the need for multiple warning slips, saving time and paper Description Item # Consecutive Employee Warning Report 4-Part, 50 Pack A2187 Small Business Essentials This CD-ROM is a powerful resource that acts as a“one-stop shop”for all the legally required forms small businesses demand. It contains more than 50 attorney-approved forms. What’s more, every form includes a tip sheet chock-full of best practices, practical pointers and compliance information. • Print as many forms as you need, when you need them • BONUS: Employee Record Retention Chart Description Item # CD-ROM A0750 Size of all forms and tip sheets: 8.5" x 11" Adobe Acrobat 5.0 or later required for downloadable forms.