# **Performance Review**

+---------------+-----------+----------------+--------+--------------+
| **Personal    |           |                |        |              |
| Data**        |           |                |        |              |
+---------------+-----------+----------------+--------+--------------+
| Employee ID   | Employee  |                | Job    |              |
|               | Name      |                | Title  |              |
+---------------+-----------+----------------+--------+--------------+
| Div           | Reviewer  |                | Review |              |
| ision/Section |           |                | Period |              |
+---------------+-----------+----------------+--------+--------------+
| **Performance |           | **Results and  |        | **Ratings**  |
| Goals and /   |           | Acc            |        |              |
| or Job        |           | omplishments** |        |              |
| Res           |           |                |        |              |
| ponsibilities |           |                |        |              |
| (Elements)**  |           |                |        |              |
+---------------+-----------+----------------+--------+--------------+
| A performance |           | Evaluate       |        | Select one   |
| goal is a     |           | results        |        | rating for   |
| statement of  |           | against        |        | each         |
| results to be |           | mutually       |        | performance  |
| achieved in a |           | established    |        | goal or job  |
| given review  |           | performance    |        | re           |
| period. Goals |           | goals and job  |        | sponsibility |
| are project   |           | res            |        | (element).   |
| or            |           | ponsibilities. |        |              |
| target-based. |           |                |        |              |
| A job         |           |                |        |              |
| r             |           |                |        |              |
| esponsibility |           |                |        |              |
| (element) is  |           |                |        |              |
| a requirement |           |                |        |              |
| that must be  |           |                |        |              |
| met on an     |           |                |        |              |
| ongoing       |           |                |        |              |
| basis. Job    |           |                |        |              |
| res           |           |                |        |              |
| ponsibilities |           |                |        |              |
| define        |           |                |        |              |
| routine tasks |           |                |        |              |
| or essential  |           |                |        |              |
| functions.    |           |                |        |              |
+---------------+-----------+----------------+--------+--------------+
| 1\. As an     |           |                |        | \_\_\_       |
| employee of   |           |                |        | Outstanding  |
| Fermilab, you |           |                |        |              |
| will          |           |                |        | \_\_\_       |
| demonstrate   |           |                |        | Excellent    |
| support for   |           |                |        |              |
| the ES&H      |           |                |        | \_\_\_       |
| Program by    |           |                |        | Commendable  |
| staying       |           |                |        |              |
| current with  |           |                |        | \_\_\_ Fully |
| all required  |           |                |        | competent    |
| ES&H          |           |                |        |              |
| training;     |           |                |        | \_\_\_ Meets |
| planning and  |           |                |        | minimal      |
| executing all |           |                |        | expectations |
| assigned work |           |                |        |              |
| activities so |           |                |        | \_\_\_ Does  |
| as to         |           |                |        | not\         |
| minimize the  |           |                |        | meet         |
| risk of       |           |                |        | expectations |
| injury or     |           |                |        |              |
| illness to    |           |                |        |              |
| yourself or   |           |                |        |              |
| others;       |           |                |        |              |
| making        |           |                |        |              |
| suggestions   |           |                |        |              |
| for improving |           |                |        |              |
| the safety or |           |                |        |              |
| environmental |           |                |        |              |
| performance   |           |                |        |              |
| of the        |           |                |        |              |
| Laboratory;   |           |                |        |              |
| reporting any |           |                |        |              |
| work-related  |           |                |        |              |
| injuries or   |           |                |        |              |
| near-misses   |           |                |        |              |
| promptly to   |           |                |        |              |
| your          |           |                |        |              |
| supervisor;   |           |                |        |              |
| and taking    |           |                |        |              |
| measures to   |           |                |        |              |
| protect and   |           |                |        |              |
| preserve the  |           |                |        |              |
| Fermilab      |           |                |        |              |
| environment,  |           |                |        |              |
| where         |           |                |        |              |
| appropriate.  |           |                |        |              |
+---------------+-----------+----------------+--------+--------------+
| 2\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 3\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 4\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 5\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 6\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 7\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 8\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 9\.           |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+
| 10\.          |           |                |        | \_\_\_       |
|               |           |                |        | Outstanding  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Excellent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_       |
|               |           |                |        | Commendable  |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Fully |
|               |           |                |        | competent    |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Meets |
|               |           |                |        | minimal      |
|               |           |                |        | expectations |
|               |           |                |        |              |
|               |           |                |        | \_\_\_ Does  |
|               |           |                |        | not\         |
|               |           |                |        | meet         |
|               |           |                |        | expectations |
+---------------+-----------+----------------+--------+--------------+

+---------------+---+-----------------------------------------------------+
| **Core        |   | **Competency Ratings**                              |
| C             |   |                                                     |
| ompetencies** |   |                                                     |
+---------------+---+-----------------------------------------------------+
| Select one    |   |                                                     |
| rating for    |   |                                                     |
| each          |   |                                                     |
| competency    |   |                                                     |
+---------------+---+-----------------------------------------------------+
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+---------------+---+-----------------------------------------------------+
| Judgment      | T |                                                     |
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+---------------+---+-----------------------------------------------------+
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+---------------+---+-----------------------------------------------------+
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+---------------+---+-----------------------------------------------------+
| Reliability   | T |                                                     |
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|               | c |                                                     |
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|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
|               | e |                                                     |
|               | x |                                                     |
|               | p |                                                     |
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|               | c |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
| Commitment to | A |                                                     |
| Safety        | b |                                                     |
|               | i |                                                     |
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|               | x |                                                     |
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|               | a |                                                     |
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|               | n |                                                     |
|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
| Support of    | D |                                                     |
| Diversity     | e |                                                     |
|               | m |                                                     |
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|               | M |                                                     |
|               | e |                                                     |
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|               | s |                                                     |
|               | m |                                                     |
|               | i |                                                     |
|               | n |                                                     |
|               | i |                                                     |
|               | m |                                                     |
|               | a |                                                     |
|               | l |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
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|               | _ |                                                     |
|               | D |                                                     |
|               | o |                                                     |
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|               | n |                                                     |
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|               | t |                                                     |
|               | m |                                                     |
|               | e |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               |   |                                                     |
|               | c |                                                     |
|               | o |                                                     |
|               | m |                                                     |
|               | p |                                                     |
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|               | t |                                                     |
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|               | n |                                                     |
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|               | x |                                                     |
|               | p |                                                     |
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|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
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|               | n |                                                     |
|               | s |                                                     |
|               | e |                                                     |
|               | x |                                                     |
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|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
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|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
| *             |   |                                                     |
| *Job-specific |   |                                                     |
| Competencies  |   |                                                     |
| (Optional)**  |   |                                                     |
+---------------+---+-----------------------------------------------------+
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | O |                                                     |
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|               | t |                                                     |
|               | a |                                                     |
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|               | d |                                                     |
|               | i |                                                     |
|               | n |                                                     |
|               | g |                                                     |
|               | \ |                                                     |
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|               | _ |                                                     |
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|               | m |                                                     |
|               | m |                                                     |
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|               | d |                                                     |
|               | a |                                                     |
|               | b |                                                     |
|               | l |                                                     |
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|               | _ |                                                     |
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|               | _ |                                                     |
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|               | \ |                                                     |
|               | _ |                                                     |
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|               | _ |                                                     |
|               | M |                                                     |
|               | e |                                                     |
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|               | t |                                                     |
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|               | m |                                                     |
|               | i |                                                     |
|               | n |                                                     |
|               | i |                                                     |
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|               | a |                                                     |
|               | l |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | D |                                                     |
|               | o |                                                     |
|               | e |                                                     |
|               | s |                                                     |
|               | n |                                                     |
|               | o |                                                     |
|               | t |                                                     |
|               | m |                                                     |
|               | e |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               |   |                                                     |
|               | c |                                                     |
|               | o |                                                     |
|               | m |                                                     |
|               | p |                                                     |
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|               | t |                                                     |
|               | e |                                                     |
|               | n |                                                     |
|               | t |                                                     |
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|               | x |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | c |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
|               | e |                                                     |
|               | x |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | c |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | O |                                                     |
|               | u |                                                     |
|               | t |                                                     |
|               | s |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | n |                                                     |
|               | d |                                                     |
|               | i |                                                     |
|               | n |                                                     |
|               | g |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | E |                                                     |
|               | x |                                                     |
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|               | l |                                                     |
|               | e |                                                     |
|               | n |                                                     |
|               | t |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | C |                                                     |
|               | o |                                                     |
|               | m |                                                     |
|               | m |                                                     |
|               | e |                                                     |
|               | n |                                                     |
|               | d |                                                     |
|               | a |                                                     |
|               | b |                                                     |
|               | l |                                                     |
|               | e |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | F |                                                     |
|               | u |                                                     |
|               | l |                                                     |
|               | l |                                                     |
|               | y |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | M |                                                     |
|               | e |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               | s |                                                     |
|               | m |                                                     |
|               | i |                                                     |
|               | n |                                                     |
|               | i |                                                     |
|               | m |                                                     |
|               | a |                                                     |
|               | l |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | D |                                                     |
|               | o |                                                     |
|               | e |                                                     |
|               | s |                                                     |
|               | n |                                                     |
|               | o |                                                     |
|               | t |                                                     |
|               | m |                                                     |
|               | e |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               |   |                                                     |
|               | c |                                                     |
|               | o |                                                     |
|               | m |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               | e |                                                     |
|               | n |                                                     |
|               | t |                                                     |
|               | e |                                                     |
|               | x |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | c |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
|               | e |                                                     |
|               | x |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | c |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | O |                                                     |
|               | u |                                                     |
|               | t |                                                     |
|               | s |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | n |                                                     |
|               | d |                                                     |
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|               | _ |                                                     |
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|               | m |                                                     |
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|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
|               | \ |                                                     |
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|               | n |                                                     |
|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | O |                                                     |
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|               | t |                                                     |
|               | s |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | n |                                                     |
|               | d |                                                     |
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|               | g |                                                     |
|               | \ |                                                     |
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|               | \ |                                                     |
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|               | \ |                                                     |
|               | _ |                                                     |
|               | C |                                                     |
|               | o |                                                     |
|               | m |                                                     |
|               | m |                                                     |
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|               | d |                                                     |
|               | a |                                                     |
|               | b |                                                     |
|               | l |                                                     |
|               | e |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | F |                                                     |
|               | u |                                                     |
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|               | _ |                                                     |
|               | M |                                                     |
|               | e |                                                     |
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|               | t |                                                     |
|               | s |                                                     |
|               | m |                                                     |
|               | i |                                                     |
|               | n |                                                     |
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|               | m |                                                     |
|               | a |                                                     |
|               | l |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | D |                                                     |
|               | o |                                                     |
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|               | o |                                                     |
|               | t |                                                     |
|               | m |                                                     |
|               | e |                                                     |
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|               |   |                                                     |
|               | c |                                                     |
|               | o |                                                     |
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|               | x |                                                     |
|               | p |                                                     |
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|               | a |                                                     |
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|               | n |                                                     |
|               | s |                                                     |
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|               | x |                                                     |
|               | p |                                                     |
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|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
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|               | n |                                                     |
|               | s |                                                     |
+---------------+---+-----------------------------------------------------+
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | O |                                                     |
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|               | t |                                                     |
|               | s |                                                     |
|               | t |                                                     |
|               | a |                                                     |
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|               | d |                                                     |
|               | i |                                                     |
|               | n |                                                     |
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|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | E |                                                     |
|               | x |                                                     |
|               | c |                                                     |
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|               | l |                                                     |
|               | e |                                                     |
|               | n |                                                     |
|               | t |                                                     |
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|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | C |                                                     |
|               | o |                                                     |
|               | m |                                                     |
|               | m |                                                     |
|               | e |                                                     |
|               | n |                                                     |
|               | d |                                                     |
|               | a |                                                     |
|               | b |                                                     |
|               | l |                                                     |
|               | e |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | F |                                                     |
|               | u |                                                     |
|               | l |                                                     |
|               | l |                                                     |
|               | y |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | M |                                                     |
|               | e |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               | s |                                                     |
|               | m |                                                     |
|               | i |                                                     |
|               | n |                                                     |
|               | i |                                                     |
|               | m |                                                     |
|               | a |                                                     |
|               | l |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | \ |                                                     |
|               | _ |                                                     |
|               | D |                                                     |
|               | o |                                                     |
|               | e |                                                     |
|               | s |                                                     |
|               | n |                                                     |
|               | o |                                                     |
|               | t |                                                     |
|               | m |                                                     |
|               | e |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               |   |                                                     |
|               | c |                                                     |
|               | o |                                                     |
|               | m |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | t |                                                     |
|               | e |                                                     |
|               | n |                                                     |
|               | t |                                                     |
|               | e |                                                     |
|               | x |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | c |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
|               | e |                                                     |
|               | x |                                                     |
|               | p |                                                     |
|               | e |                                                     |
|               | c |                                                     |
|               | t |                                                     |
|               | a |                                                     |
|               | t |                                                     |
|               | i |                                                     |
|               | o |                                                     |
|               | n |                                                     |
|               | s |                                                     |
+---------------+---+-----------------------------------------------------+

+---------------+------------------------------------------------------+
| **Manageria   |                                                      |
| l/Supervisory |                                                      |
| Competencies  |                                                      |
| (For          |                                                      |
| employees who |                                                      |
| supervise     |                                                      |
| others)**     |                                                      |
+---------------+------------------------------------------------------+
| **Values and  | Demonstrates respect for people and Laboratory       |
| Ethics:**     | principles and policies. Maintains a respectful,     |
| *Integrity    | diverse and inclusive work environment. Holds self   |
| and Respect*  | and others accountable for actions.                  |
|               |                                                      |
|               | \_\_ Outstanding \_\_Excellent \_\_ Commendable \_\_ |
|               | Fully \_\_ Meets minimal \_\_ Does not meet          |
|               |                                                      |
|               | competent expectations expectations                  |
+---------------+------------------------------------------------------+
| **Strategic   | Offers advice and creates plans based on analysis of |
| Thinking:     | issues and trends and links these to the             |
|   ***Analysis | responsibilities, capabilities and potential of      |
| and Ideas*    | his/her organization. Scans an ever-changing,        |
|               | complex environment in anticipation of emerging      |
|               | opportunities and possible crises. Develops          |
|               | well-informed advice and strategies that are         |
|               | sensitive to the needs of various groups served.     |
|               |                                                      |
|               | \_\_ Outstanding \_\_Excellent \_\_ Commendable \_\_ |
|               | Fully \_\_ Meets minimal \_\_ Does not meet          |
|               |                                                      |
|               | competent expectations expectations                  |
+---------------+------------------------------------------------------+
| **Engagement  | Engages employees, teams and collaborators in        |
| :  ***People, | developing goals, executing plans and delivering     |
| Teams,        | results. Motivates employees and teams to accomplish |
| C             | goals by communicating clearly and consistently.     |
| ollaborators* | Uses negotiation skills and models adaptability to   |
|               | encourage recognition of joint concerns. Uses        |
|               | collaboration and influence skills to achieve        |
|               | successful outcomes.                                 |
|               |                                                      |
|               | \_\_ Outstanding \_\_Excellent \_\_ Commendable \_\_ |
|               | Fully \_\_ Meets minimal \_\_ Does not meet          |
|               |                                                      |
|               | competent expectations expectations                  |
+---------------+------------------------------------------------------+
| **Management  | Aligns people, work and systems with the             |
| E             | Laboratory's strategy. Ensures that the staff has    |
| xcellence: ** | the knowledge, skills and versatility to meet        |
|               | current and longer-term goals. Ensures that people   |
|               | have the support and tools they need to succeed in   |
|               | their work. Manages the performance management cycle |
|               | effectively by developing mutual performance goals   |
|               | with employees, providing ongoing performance        |
|               | feedback throughout the year, and conducting timely  |
|               | performance review discussions and documentation.    |
|               |                                                      |
|               | \_\_ Outstanding \_\_Excellent \_\_ Commendable \_\_ |
|               | Fully \_\_ Meets minimal \_\_ Does not meet          |
|               |                                                      |
|               | competent expectations expectations                  |
+---------------+------------------------------------------------------+
| **Resource    | Accesses and reviews standard budget reports as      |
| Management:** | appropriate. Reallocates resources as organizational |
|               | change occurs. Gathers and organizes credible data   |
|               | to make a case for budget changes. Regularly         |
|               | analyzes budget data to ensure cost effectiveness    |
|               | and efficiency.                                      |
|               |                                                      |
|               | \_\_ Outstanding \_\_Excellent \_\_ Commendable \_\_ |
|               | Fully \_\_ Meets minimal \_\_ Does not meet          |
|               |                                                      |
|               | competent expectations expectations                  |
+---------------+------------------------------------------------------+
| **Summary of  |                                                      |
| Performance   |                                                      |
| and Review of |                                                      |
| C             |                                                      |
| ompetencies** |                                                      |
+---------------+------------------------------------------------------+
|               |                                                      |
+---------------+------------------------------------------------------+
| **Career      |                                                      |
| Development   |                                                      |
| Plan          |                                                      |
| (Optional)**  |                                                      |
+---------------+------------------------------------------------------+
|               |                                                      |
+---------------+------------------------------------------------------+

+----------+---+--------+---------+---+----------+----------+-----------+
| **Sign   |   |        |         |   |          |          |           |
| atures** |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **       |   |        |         |   |          |          |           |
| Employee |   |        |         |   |          |          |           |
| Acknowl  |   |        |         |   |          |          |           |
| edgement |   |        |         |   |          |          |           |
| of       |   |        |         |   |          |          |           |
| Per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| G        |   |        |         |   |          |          |           |
| oals/Job |   |        |         |   |          |          |           |
| Responsi |   |        |         |   |          |          |           |
| bilities |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| Compet   |   |        |         |   |          |          |           |
| encies** |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| My       |   |        |         |   |          |          |           |
| su       |   |        |         |   |          |          |           |
| pervisor |   |        |         |   |          |          |           |
| /manager |   |        |         |   |          |          |           |
| and I    |   |        |         |   |          |          |           |
| id       |   |        |         |   |          |          |           |
| entified |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| d        |   |        |         |   |          |          |           |
| iscussed |   |        |         |   |          |          |           |
| my       |   |        |         |   |          |          |           |
| per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| goals,   |   |        |         |   |          |          |           |
| job      |   |        |         |   |          |          |           |
| responsi |   |        |         |   |          |          |           |
| bilities |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| job      |   |        |         |   |          |          |           |
| -related |   |        |         |   |          |          |           |
| comp     |   |        |         |   |          |          |           |
| etencies |   |        |         |   |          |          |           |
| at the   |   |        |         |   |          |          |           |
| b        |   |        |         |   |          |          |           |
| eginning |   |        |         |   |          |          |           |
| of the   |   |        |         |   |          |          |           |
| review   |   |        |         |   |          |          |           |
| period.  |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| Employee |   |        |         |   |          |          |           |
| S        |   |        |         |   |          |          |           |
| ignature |   |        |         |   |          |          |           |
| \_       |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| Date     |   |        |         |   |          |          |           |
| \_       |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **       |   |        |         |   |          |          |           |
| Progress |   |        |         |   |          |          |           |
| Review   |   |        |         |   |          |          |           |
| (Opt     |   |        |         |   |          |          |           |
| ional)** |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| My       |   |        |         |   |          |          |           |
| su       |   |        |         |   |          |          |           |
| pervisor |   |        |         |   |          |          |           |
| /manager |   |        |         |   |          |          |           |
| and I    |   |        |         |   |          |          |           |
| d        |   |        |         |   |          |          |           |
| iscussed |   |        |         |   |          |          |           |
| my       |   |        |         |   |          |          |           |
| perf     |   |        |         |   |          |          |           |
| ormance. |   |        |         |   |          |          |           |
| We have  |   |        |         |   |          |          |           |
| updated  |   |        |         |   |          |          |           |
| g        |   |        |         |   |          |          |           |
| oals/job |   |        |         |   |          |          |           |
| responsi |   |        |         |   |          |          |           |
| bilities |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| compe    |   |        |         |   |          |          |           |
| tencies\ |   |        |         |   |          |          |           |
| (if      |   |        |         |   |          |          |           |
| needed). |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| Employee |   |        |         |   |          |          |           |
| S        |   |        |         |   |          |          |           |
| ignature |   |        |         |   |          |          |           |
| \_       |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| Date     |   |        |         |   |          |          |           |
| \_\_     |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| *        |   |        |         |   |          |          |           |
| *Overall |   |        |         |   |          |          |           |
| Rating** |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **Select |   |        |         |   |          |          |           |
| only one |   |        |         |   |          |          |           |
| rating   |   |        |         |   |          |          |           |
| -**      |   |        |         |   |          |          |           |
| Assign   |   |        |         |   |          |          |           |
| an       |   |        |         |   |          |          |           |
| Overall  |   |        |         |   |          |          |           |
| Rating   |   |        |         |   |          |          |           |
| based on |   |        |         |   |          |          |           |
| Accompl  |   |        |         |   |          |          |           |
| ishments |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| C        |   |        |         |   |          |          |           |
| ompetenc |   |        |         |   |          |          |           |
| ies**.** |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| *        |   |        |         |   |          |          |           |
| *Overall |   |        |         |   |          |          |           |
| Ratings  |   |        |         |   |          |          |           |
| with     |   |        |         |   |          |          |           |
| Descri   |   |        |         |   |          |          |           |
| ptors.** |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| \_\_\_   | \ |        | \_\_\_  |   | \_\_\_   | \_\_\_   | \_\_\_    |
| Out      | _ |        | Comm    |   | Fully    | Meets    | Does not  |
| standing | \ |        | endable |   |          | Minimal  | meet      |
|          | _ |        |         |   | c        |          |           |
|          | \ |        |         |   | ompetent | expe     | exp       |
|          | _ |        |         |   |          | ctations | ectations |
|          | E |        |         |   |          |          |           |
|          | x |        |         |   |          |          |           |
|          | c |        |         |   |          |          |           |
|          | e |        |         |   |          |          |           |
|          | l |        |         |   |          |          |           |
|          | l |        |         |   |          |          |           |
|          | e |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | t |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **Out    | * |        | **Good, |   | **Good,  | **Perfo  | **Pe      |
| standing | * |        | solid   |   | solid    | rmance** | rformance |
| perfo    | E |        | perform |   | perfor   | **leaves | is**      |
| rmance** | x |        | ance**. |   | mance**. | room for | **well    |
| **that   | c |        | F       |   | Fulfills | improv   | below the |
| results  | e |        | ulfills |   | all      | ement**. | minimum   |
| in**     | l |        | all     |   | position | Employee | position  |
| **extra  | l |        | p       |   | requ     | requires | requir    |
| ordinary | e |        | osition |   | irements | either   | ements.** |
| and      | n |        | requi   |   | and      | **ad     | Requires  |
| exc      | t |        | rements |   | goals.   | ditional | immediate |
| eptional | p |        | and     |   |          | dev      | review    |
| accompl  | e |        | goals   |   |          | elopment | and       |
| ishments | r |        | and     |   |          | in       | action    |
| with     | f |        | **may,  |   |          | d        | including |
| sig      | o |        | on      |   |          | eficient | **imple   |
| nificant | r |        | occa    |   |          | t        | mentation |
| contrib  | m |        | sion,** |   |          | echnical | of        |
| utions** | a |        | g       |   |          | areas**; | Pe        |
| to goals | n |        | enerate |   |          | **or,    | rformance |
| of the   | c |        | results |   |          | may be a | Im        |
| Dep      | e |        | above   |   |          | new hire | provement |
| artment, | * |        | those   |   |          | req      | Plan      |
| Division | * |        | e       |   |          | uiring** | (PIP).**  |
| or       | * |        | xpected |   |          | **fam    |           |
| Lab      | * |        | of the  |   |          | iliarity |           |
| oratory. | t |        | po      |   |          | with lab |           |
|          | h |        | sition. |   |          | pr       |           |
|          | a |        |         |   |          | ocesses; |           |
|          | t |        |         |   |          | or, is   |           |
|          | * |        |         |   |          | not      |           |
|          | * |        |         |   |          | re       |           |
|          | * |        |         |   |          | sponding |           |
|          | * |        |         |   |          | f        |           |
|          | c |        |         |   |          | avorably |           |
|          | o |        |         |   |          | to       |           |
|          | n |        |         |   |          | coaching |           |
|          | s |        |         |   |          | for      |           |
|          | i |        |         |   |          | per      |           |
|          | s |        |         |   |          | formance |           |
|          | t |        |         |   |          | improv   |           |
|          | e |        |         |   |          | ement.** |           |
|          | n |        |         |   |          |          |           |
|          | t |        |         |   |          |          |           |
|          | l |        |         |   |          |          |           |
|          | y |        |         |   |          |          |           |
|          | g |        |         |   |          |          |           |
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|          | . |        |         |   |          |          |           |
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|          | c |        |         |   |          |          |           |
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|          | n |        |         |   |          |          |           |
|          | t |        |         |   |          |          |           |
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|          | a |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
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|          | r |        |         |   |          |          |           |
|          | t |        |         |   |          |          |           |
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|          | t |        |         |   |          |          |           |
|          | e |        |         |   |          |          |           |
|          | c |        |         |   |          |          |           |
|          | h |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | i |        |         |   |          |          |           |
|          | c |        |         |   |          |          |           |
|          | a |        |         |   |          |          |           |
|          | l |        |         |   |          |          |           |
|          | a |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | d |        |         |   |          |          |           |
|          | f |        |         |   |          |          |           |
|          | u |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | c |        |         |   |          |          |           |
|          | t |        |         |   |          |          |           |
|          | i |        |         |   |          |          |           |
|          | o |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | a |        |         |   |          |          |           |
|          | l |        |         |   |          |          |           |
|          | i |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | o |        |         |   |          |          |           |
|          | v |        |         |   |          |          |           |
|          | a |        |         |   |          |          |           |
|          | t |        |         |   |          |          |           |
|          | i |        |         |   |          |          |           |
|          | o |        |         |   |          |          |           |
|          | n |        |         |   |          |          |           |
|          | s |        |         |   |          |          |           |
|          | . |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **Seco   |   |        |         |   |          |          |           |
| nd-level |   |        |         |   |          |          |           |
| Ma       |   |        |         |   |          |          |           |
| nagerial |   |        |         |   |          |          |           |
| Approval |   |        |         |   |          |          |           |
| of       |   |        |         |   |          |          |           |
| Per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| Review   |   |        |         |   |          |          |           |
| Do       |   |        |         |   |          |          |           |
| cument** |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| I have   |   |        |         |   |          |          |           |
| reviewed |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| approved |   |        |         |   |          |          |           |
| the      |   |        |         |   |          |          |           |
| per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| review   |   |        |         |   |          |          |           |
| document |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| overall  |   |        |         |   |          |          |           |
| rating.  |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| S        |   |        |         |   |          |          |           |
| ignature |   |        |         |   |          |          |           |
| \_\_\_   |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| Date     |   |        |         |   |          |          |           |
| \_\_     |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| (Manager |   |        |         |   |          |          |           |
| of       |   |        |         |   |          |          |           |
| r        |   |        |         |   |          |          |           |
| eviewer) |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **       |   |        |         |   |          |          |           |
| Reviewer |   |        |         |   |          |          |           |
| Acknowl  |   |        |         |   |          |          |           |
| edgement |   |        |         |   |          |          |           |
| of       |   |        |         |   |          |          |           |
| Per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| Review   |   |        |         |   |          |          |           |
| Do       |   |        |         |   |          |          |           |
| cument** |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| I have   |   |        |         |   |          |          |           |
| d        |   |        |         |   |          |          |           |
| iscussed |   |        |         |   |          |          |           |
| the      |   |        |         |   |          |          |           |
| per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| review   |   |        |         |   |          |          |           |
| document |   |        |         |   |          |          |           |
| with the |   |        |         |   |          |          |           |
| employee |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| advised  |   |        |         |   |          |          |           |
| the      |   |        |         |   |          |          |           |
| employee |   |        |         |   |          |          |           |
| of       |   |        |         |   |          |          |           |
| his/her  |   |        |         |   |          |          |           |
| overall  |   |        |         |   |          |          |           |
| rating.  |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| Reviewer |   |        |         |   |          |          |           |
| S        |   |        |         |   |          |          |           |
| ignature |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| Date     |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| (Person  |   |        |         |   |          |          |           |
| who      |   |        |         |   |          |          |           |
| prepared |   |        |         |   |          |          |           |
| the      |   |        |         |   |          |          |           |
| review)  |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **       |   |        |         |   |          |          |           |
| Employee |   |        |         |   |          |          |           |
| Acknowl  |   |        |         |   |          |          |           |
| edgement |   |        |         |   |          |          |           |
| of       |   |        |         |   |          |          |           |
| Per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| Review   |   |        |         |   |          |          |           |
| Disc     |   |        |         |   |          |          |           |
| ussion** |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| My       |   |        |         |   |          |          |           |
| su       |   |        |         |   |          |          |           |
| pervisor |   |        |         |   |          |          |           |
| /manager |   |        |         |   |          |          |           |
| has      |   |        |         |   |          |          |           |
| reviewed |   |        |         |   |          |          |           |
| and      |   |        |         |   |          |          |           |
| d        |   |        |         |   |          |          |           |
| iscussed |   |        |         |   |          |          |           |
| the      |   |        |         |   |          |          |           |
| per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| review   |   |        |         |   |          |          |           |
| document |   |        |         |   |          |          |           |
| with me. |   |        |         |   |          |          |           |
| My       |   |        |         |   |          |          |           |
| s        |   |        |         |   |          |          |           |
| ignature |   |        |         |   |          |          |           |
| means    |   |        |         |   |          |          |           |
| that I   |   |        |         |   |          |          |           |
| have     |   |        |         |   |          |          |           |
| been     |   |        |         |   |          |          |           |
| advised  |   |        |         |   |          |          |           |
| of my    |   |        |         |   |          |          |           |
| per      |   |        |         |   |          |          |           |
| formance |   |        |         |   |          |          |           |
| status   |   |        |         |   |          |          |           |
| and does |   |        |         |   |          |          |           |
| not      |   |        |         |   |          |          |           |
| nec      |   |        |         |   |          |          |           |
| essarily |   |        |         |   |          |          |           |
| imply    |   |        |         |   |          |          |           |
| that I   |   |        |         |   |          |          |           |
| agree    |   |        |         |   |          |          |           |
| with it. |   |        |         |   |          |          |           |
|          |   |        |         |   |          |          |           |
| Employee |   |        |         |   |          |          |           |
| S        |   |        |         |   |          |          |           |
| ignature |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| Date     |   |        |         |   |          |          |           |
| \_       |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
| \_\_\_\_ |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **       |   |        |         |   |          |          |           |
| Employee |   |        |         |   |          |          |           |
| Comments |   |        |         |   |          |          |           |
| (Opt     |   |        |         |   |          |          |           |
| ional)** |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+
| **Mentor |   |        |         |   |          |          |           |
| Comments |   |        |         |   |          |          |           |
| (Opt     |   |        |         |   |          |          |           |
| ional)** |   |        |         |   |          |          |           |
+----------+---+--------+---------+---+----------+----------+-----------+