This form is to be used to record the discussion of the rated employee's performance that are a mandatory part of the
performance evaluation process. To support the certification statement in the EER form, a minimum of two discussions
must occur in each rating cycle, and at least one of them must be documented on this form.
U. S. Department of State
Name of Employee
Employee Identification Number
Name of Rating Official
Date (mm-dd-yyyy) Period Covered
From (mm-dd-yyyy) To (mm-dd-yyyy)
The purpose of this form is twofold: to serve as a record that a thorough performance discussion occurred, and to help
ensure that the rating officer and rated employee have a compatible view of the outcome. Notations in the sections can
be brief and should aim to highlight major points of the discussion of performance. A copy must be provided to the
rated employee. The rating officer should keep the original for his own records. Use a separate copy of the form to
document each discussion.
Discussion of Overall Performance: The rating officer should briefly characterize the rated employee's overall
performance and cite examples as appropriate. The following items should be components in each discussion:
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Are the work requirements being met
Should the work requirements be changed? If so, how?
Is there appropriate supervision and guidance?
General discussion of performance.
(Last, First, MI.)
(as outlined at the start of the rating period)?
Employee Comments: The rated employee is encouraged to provide comments, but is not required to do so. The
rated employee's signature on the form does not imply full agreement with all the comments recorded, but confirms that
the counseling session took place as required.
Rating Officer
Date (mm-dd-yyyy)
Rated Employee
Date (mm-dd-yyyy)
Area for Improvement: Note aspects of performance that need to be improved to better meet the requirements of
current assignment as well as to enhance the employee's potential for assuming greater responsibility.
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