College of Medicine (For Internal Use Only)

360-Degree Performance Evaluation Form [Appraisal period from 1/1/10 to 12/31/10]

This form will assist management in preparing the performance evaluation for the individual listed below. As someone who wor s with this person on a regular basis! "our feedbac regarding his or her performance will be useful to the overall review process. #ou are not re$uired to put "our name on this form.

Employee Name:

________________________________________________

Relation to Employee:________________________________________________ Yo r Name (Optional): ________________________________________________ A few times a week A few times a month

Time Spent Yo r interaction !it" employee

Every Day

Every few months

NA (Never)

Strongly Agree Quality of Work #ets "ig" standards for $ ality of !or% o tp t Ens res !or% is error&free 'efore s 'mitting (elps ot"ers impro)e t"e $ ality of t"eir !or%

Agree

Disagree

Strongly Disagree

Not Applica le

!ommunication Comm nicates !ell orally and in !ritten&form *isplays good listening s%ills #"ares information freely !it" ot"ers

Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applica le

Teamwork Contri' tes positi)ely to team (elps define team roles to ma+imi,e o tp t Can 'e co nted on to

Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applica le

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College of Medicine (For Internal Use Only)

complete tas%s correctly

"ersonal Qualifications an# $ea#ership 7resents a positi)e image to o tsiders Is friendly and easy to !or% !it" 3dapts !ell to c"ange (as "ig" professional and et"ical standards

Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applica le

7lease pro)ide additional comments in t"e space 'elo! 89ype comments "ere:

-an ary ./ 0112/ Re)ision 3nn al 'y College of Medicine ( man Reso rces

04040156