PLEASE RETURN THIS COMPLETED FORM TO HUMAN RESOURCES
(The original of this evaluation will be placed in the employee’s personnel file.)
Supervisor & Employee: Please retain a copy for your files prior to forwarding to Human Resources.
Rev 02/03/2020
Considering all factors carefully, and giving weight to those factors most
important in this job, rate the composite, overall performance
of this employee.
F. ADDITIONAL COMMENTS BY IMMEDIATE SUPERVISOR:
If signing this form electronically, I recognize that it will be considered as effective and valid as the original.
Supervisor Signature Date
G. COMMENTS BY NEXT HIGHER SUPERVISOR: (Must be completed prior to meeting with employee)
If signing this form electronically, I recognize that it will be considered as effective and valid as the original.
Next Higher Supervisor Signature Date
H. EMPLOYEE'S ACKNOWLEDGEMENT: I have reviewed and discussed the contents of this evaluation with my supervisor
and understand that my signature does not necessarily indicate agreement. I understand that I may request a copy of my
evaluation at this time and that I may make comments below or submit a written rebuttal statement within 10 working days.
I further understand that if I submit a written rebuttal statement, it will be attached to and become a part of this evaluation.
(Section 9.3 2019-2021 NSCPA)
Employee’s Comments:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Employee’s Signature ________________________________ Date ________________
