1. Name of Employee Being Rated (Last, First, MI)
Signature of Rater
Examples Provided?
Inadmissible Material?
YES NO YES NO
Work Responsibilities Established Date (mm-dd-yyyy) Work Responsibilities Revised Date (mm-dd-yyyy)
Professional Development Date (mm-dd-yyyy) Professional Development Date (mm-dd-yyyy)
Rater Name Rater Position
Reviewer Name Reviewer Position
Name of Review Panel Chairperson
Review Panel Chairperson Position
Grade
Grade
Date (mm-dd-yyyy)
Signature of Reviewer Date (mm-dd-yyyy)
Signature of Rated Employee Date (mm-dd-yyyy)
Signature of Review Panel Chairperson Date (mm-dd-yyyy)
2. Grade
6. Date (mm-dd-yyyy)4. Post or Organization
5. Position Title
3. Employee ID Number
Date Received in Post/Bureau (mm-dd-yyyy) Date Received in HR/PE (mm-dd-yyyy) Period Covered (mm-dd-yyyy)
From: To:
C. Core Work Responsibilities:
Model the Department of State's six core values (accountability, character, community, diversity, loyalty, service) and the Department's Leadership and Management Principles; observe and implement
EEO principles.
Security Responsibilities
Entry Level: Practice security awareness; report and/or address possible safety hazards and/or unsafe practices; follow security directives, regulations, and policies; safeguard classified information,
material, and equipment.
Tenured Mid Level: Ensure active risk management through monitoring the security environment concurrent to the scope of official duties and responsibilities; follow security directives, regulations, and
policies; safeguard classified information, material, and equipment.
Senior Level: Ensure active risk management by themselves and staff members within their scope of duties and responsibilities, including promotion of security consciousness and implementing and/or
following security directives,regulations, and policies; safeguard classified information, material, and equipment.
III. ORGANIZATIONAL CONTEXT, CIRCUMSTANCES, GOALS
A. Organizational Context:
B. Organizational Circumstances: (UNFORESEEN, UNANTICIPATED EVENTS THAT AFFECTED OPERATIONS)
I. EMPLOYEE'S DUTIES
U.S. Department of State
EMPLOYEE EVALUATION REPORT
OPTIONAL SHORT FORM: FOR PERIODS OF FEWER THAN 120 DAYS
When completed on Foreign Service personnel, this is an evaluation report which shall be subject
to inspection only by those persons authorized by Sec. 604 of the Foreign Service Act of 1980.
DS-7768
05-2017
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II. WORK RESPONSIBILITIES, COUNSELING, REVIEW PANEL
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IV . EVALUATION OF PERFORMANCE (Completed by Rater)
V. DEVELOPMENTAL AREA (Completed by Rater)
D. Core Work Requirements. Goals/Specific Objectives:
III. ORGANIZATIONAL CONTEXT, CIRCUMSTANCES, GOALS (Cont.)
DS-7768
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VI. OPTIONAL STATEMENT BY RATED EMPLOYEE
The rated employee may use this section to address activities or problems that the Rater or Reviewer did not adequately cover or aspects of the report
he or she believes should be clarified or corrected. Continuation sheets may be used.
Competency that needed the most strengthening over this rating period; Cite Example(s) from this rating period.
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