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
E. 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
F. 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
G. EMPLOYEE'S STATEMENT: I have reviewed and discussed the contents of this evaluation with my supervisor and
understand that my signature does not necessarily indicate agreement. I further understand that I may submit a written
rebuttal statement which will be attached to and become a permanent part of this evaluation. I also understand I may write
comments where indicated.
Employee’s Comments:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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Signature _____________________________________ Date ________________
