See Instructions Before Completing (DS-5055i)
U.S. Department of State
U.S. FOREIGN SERVICE EMPLOYEE EVALUATION REPORT
DATE RECEIVED IN POST/BUREAU (mm-dd-yyyy)
GRADE
DATE RECEIVED IN HR/PE (mm-dd-yyyy)
NAME OF EMPLOYEE BEING RATED (Last, First, MI)
EMPLOYEE IDENTIFICATION NUMBER
When completed on a Foreign Service employee, this is a performance evaluation report that shall be subject to
inspection only by those persons authorized by Sec. 604 of the Foreign Service Act of 1980.
Page 1 of 4
DS-5055 (V4.1)
03-2018
Goals/Specific Objectives - List in priority order the outcomes the employee seeks to achieve in support of Mission, Bureau, or Department goals.
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:
V. POSITION DESCRIPTION, RESPONSIBILITIES, SPECIAL CIRCUMSTANCES
Position Description: Size and function of the work unit and its position within the Mission or Bureau, number of employees rated and reviewed,
amount and purpose of financial and physical resources for which the employee is accountable.
Signature of Panel Chairperson
Name of Panel Chairperson
Date (mm-dd-yyyy)
A. Examples of performance Have specific examples been provided in all sections?
B. Certification This report has been prepared according to the regulations and contains no inadmissible material.
C. If this report is late or does not conform to regulations and instructions, indicate who is responsible:
IV. REVIEW PANEL STATEMENT (Completed by Review Panel)
I acknowledge receipt of this report, which has been completed for submission to a review panel.
Signature of Rated Employee
Date (mm-dd-yyyy)
III. ACKNOWLEDGEMENT OF RECEIPT (Completed by Rated Employee)
Work responsibilities were established by rater, reviewer, and employee on (mm-dd-yyyy)
Rater and rated employee held performance review sessions on at least two dates as follows: (mm-dd-yyyy)
1. 2.
II. CERTIFICATION OF WORK RESPONSIBILITIES AND PERFORMANCE REVIEWS
Signature of Rater after completion of Sections II, V and VII
RATER - NAME, TITLE
RATER GRADE
REVIEWER - NAME, TITLE REVIEWER GRADE
I. SUBMISSION CONTROL
I consider this report to be complete, in conformance with the instructions, and adequately documented by specific examples of performance.
Date (mm-dd-yyyy)
Signature of Reviewer after completion of Section VIII
Date (mm-dd-yyyy)
TYPE OF REPORT
POSITION TITLE
POST OR ORGANIZATION PERIOD COVERED (mm-dd-yyyy)
From
To
Yes
No
Yes
No
- Entry: Practice security awareness; report and/or address possible safety hazards and/or unsafe practices; follow security regulations, and policies; safeguard
classified information, material, and equipment.
- Tenured: Ensure active risk management through monitoring the security environment concurrent to the scope of official responsibilities; follow security directives,
regulations, and policies; safeguard classified information, material, and equipment.
- Senior: Ensure active risk management by themselves and staff members within their scope of duties and responsibilities, promotion of security consciousness and
implementing and/or following security directives,regulations, and policies; safeguard classified information, material, and equipment.
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