Fillable Performance Feedback Appeal Form

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Performance Feedback Appeal Form

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BROWSE CITY (AR) FORMS

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Page 1 of 2
PERFORMANCE FEEDBACK PROCESS APPEAL FORM
An employee may appeal an annual performance feedback appraisal where it is believed that the overall rating or individual
performance factor ratings do not represent a true evaluation of the employee’s work performance during the appraisal period.
Such appeal shall follow the normal chain of command up to and including the Department Director if necessary.
Within 10 days of receipt of a signed copy of the appraisal, the employee should meet with the evaluating supervisor in an
attempt to resolve the disagreement before filing a formal appeal. Though not required at this step, the appealing employee is
encouraged to complete and utilize this Performance Feedback Appeal Form as the basis of the initial discussion with the
supervisor. If not resolved in this informal discussion, the employee may formally appeal the evaluation by completing and
submitting this Performance Feedback Appeal Form to the evaluating supervisor within 10 days after receiving the signed copy
of the performance feedback rating. If the appeal is not resolved by the immediate supervisor, it is the appellant’s
responsibility to move the appeal through the subsequent steps in a timely manner (see Performance Feedback Appeal
Procedure).
EMPLOYEE NAME: DATE:
EMPLOYEE JOB TITLE: SUPERVISOR NAME:
DATE OF EVALUATION: DATE COPY RECEIVED:
NOTE: A complete copy of the Performance Feedback Rating Form that you are appealing (signed by the evaluating
supervisor) must be submitted with this appeal at each step of the formal appeal process.
1. IDENTIFY THE SPECIFIC PERFORMANCE FACTOR RATING(S) YOU ARE CONTESTING, e.g., interpersonal
skills, flexibility/adaptability, teamwork:
2. IDENTIFY: a.) THE SUPERVISOR’S RATING FOR EACH FACTOR YOU ARE APPEALING, AND b.) THE
RATINGS YOU PROPOSE FOR EACH FACTOR YOU ARE APPEALING:
3. DESCRIBE THE SPECIFIC FACTS TO SUPPORT YOUR APPEAL OF EACH PERFORMANCE FACTOR
RATING. Attach additional sheets if necessary. (Attach applicable evidence):
__________________________________________ ____________________________________________
Signature of appellant Date Submitted to Immediate Supervisor
IMMEDIATE SUPERVISOR
__________________________________ ____________________________________________
Signature of Immediate Supervisor (reflects receipt only) Date of receipt of this completed appeal form
See page 2 for immediate supervisor decision box and signature boxes for Division Manager and Department Director.
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Page 2 of 2
PERFORMANCE FEEDBACK PROCESS APPEAL FORM
EMPLOYEE NAME: ________________________________
IMMEDIATE SUPERVISOR
The following solution was reached and the revised performance feedback appraisal form is attached:
We have not resolved this appeal; the employee may forward appeal to the next level of management.
Appellant Signature _______________________________________ Date: _____________________
Immediate Supervisor Signature: ______________________________Date: _____________________
DIVISION MANAGER / NEXT LEVEL OF MANAGEMENT ABOVE EVALUATING SUPERVISOR
Date appeal was received: _______________
The following solution was reached and the revised performance feedback appraisal form is attached:
We have not resolved this appeal; employee may forward appeal to the Department Director.
Appellant Signature _______________________________________ Date: _____________________
Division Manager Signature: _________________________________ Date: _____________________
DEPARTMENT DIRECTOR
Date appeal was received: _______________
The following solution was reached and the revised performance feedback appraisal form is attached:
We have not resolved this appeal; employee may forward appeal to the Human Resources Director.
Appellant Signature _____________________________________________ Date: _______________
Department Director Signature: ____________________________________ Date: ________________
ATTACH ADDITIONAL SHEETS IF NECESSARY.
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Performance Feedback Appeal Form

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Completed 21 March 2020

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