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 -2-

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 -4-

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llli ll 9 ( R-s CrrcLrlar

 ddlod
FORM

(4,5,6 d)€
7 de Oo$d)rJcdt d,osa)
rVide Rules 4.5.6.& 7)
'ae2 d;drid$:u eaodd cbasu-a, rbau-cs doQ r@r' -,e,
drdrjd&d e-odsa drdod duoro daddoci eo{onoarnd a-o&rd
uooJ:rpdrdrro ddooi dd.rDd

FORM OF ANNUAL PERFORMANCE REPORT APPLICABLE

TO THE GOVERNMENT SERVANTS HOLDING ALL POSTS,
i.e..GROUP-"A" "8" AND "C" POSTS.

(ad:dmo dod&a dro@ o-ouo: drodeJedc)

(To be recorded in Single/Original only) ,

.................dod1 dr:qoicuorid ddrdleodpoi ddo.

Report for the year/period ending.

w-orj-t :
--.-------------
droied droa'g

PART-1:PERSONALDATA
(ddO drode-r.d:d duaro Sdddl rnJ,3r dmdeJeuod:d:)
(To be furnished by the Government servant reported upon)

1 daoro Sddd dddl

Name of the Government Servant

2 Paoro pdd& ofdd dedci deoogd

Service to which the Govt.servant
Belongs.

3 ddr : eodpoJrg ilddso anoad dr(

Post held during the year/period

4 apood
erfrn
Date of Birth

5 noo6drd
Educational Qualification

ll1, 1-0-6ll sCircular

 -2-
a

6 ddooi erdQo$gd dd/ddde'3ojc dreeJ

ddd eodq
Period sPent on Leave/Training
during the Period of rePort
(o) dd
(a) Leave

(1) ddon *d"d

Kind of Leave

(2) eod dd.l

From To
(w) uo*e,a
Training
({ ) otn* o'deJe,3ci poloee,dcroetdge
ddejeeoir addrjdc
es

Particulars of Training to which

Deputed

(2) o-oero-oernde z
Whether attended?

(3) roeloa,Jaqg eodd" uodearJdc

lf not, reasons for not attending

7 ddaoi dfrrdg /eidQong riu,sd

aoo6drd oi:ofioaddo o{g
Qualification acquired, if any
during the period of report

8 a-o,qrd erg add d€d&a dgOd

ouood :
Date of filing the Annual property
Returns

Jd:
'@ -da-
Place: SIGNATURE

auaod dddr dcQ ddsodr

DATE NAME AND DESIGNATION
Rk-E-9-CR's Circular
 -3-

PART-II SELF ASSESSMENT

{ dda drodo@* doaro dAO& eparseupdrd.l}
.+
To be made bv the Govt.. servants reported upon

1) ddrd5rid doq4i nddrJ

Brief description of the duties:

2l d, dddod eoodcidfordcloodod duoro Pdd

pdra&d dodd doqE *oiro dioo6dndd
A brief self assessment of the work
done by the Govt.servant including the
following aspects.

,r) erddl/esd QoJ:o prJadefrd/ooedJd

ofodrcsoddta rirocJdJ
Objectives set for himself/herself if any

tsi draadJJ oJndrcmddro aded UoW'dridc

Objectives achieved

,ri ptJroO'rJdc obodtoaddo e{g

Constraints, if any

3) ddo drordtr-dld dsaro doddd),ddo d.rodld

laQuadaael{g.eldd: eodJde esd oo*qrd uaoJ:r
cdrdEaa ddoo$p de dddodod draedoddd*q'
 -4-

p-ddl d€, drood draedoflid;dedodd 6rdil * ddoo$ ddtdg oJraoct ddo

pdrdroddor,Cd'b mdadrgiedTccdod:drQp"
rypuodoandr$efoer dlOgO uooud uaolrr
(eodoarPodrd,ddh doddr ua*)

esdd so"trd aoolrr

dDerd : dda drddd EDoE-odd oe* dd8rrlc&a cad] ecdodldrogdodr
pdrdra ddso$H Arae*oOag. *oeaeoUo msbuoOd de dCdod d.sdJoo doaddt esodd
ddo drod)a o3auoo-a uo&rd uoolrr pdtdFo ddso$g oooelddd"d3,

"qDrJ-2dg ddtsedo&drdod pe7pedr,3------ --odroort dda drodrd

@06add;44*r erddgd ilo"td uoolrr Odrdruo dd0c,Cdtr esddr 6dodld,Og, eodrdood
esddl ddo a3ouoOaaer ddrd5 pdt&dldg s#ouoe)dlqd"

ln case the Government servant reported upon is himself/herself Reporting

Authority, he/she shall declare as follows in his/her Annual Performance Report:-
"l hereby declare that I have "written/"*not written{*strike-off whichever is not
applicabie) the reports in respect of all those for whom I am the Reporting
Authority for the year under report".

lnstruction:- ln case a Reporting Authority declares in his Annual Performance

Report that he/she has not written all the Reports, the Reviewing Authority shall
make the followin$ adverse entrY:-

"According to his/her own declaration in Part-ll Shri / Smt

has not written the Annual Performance Reports all those for whom he/she is the
Reporting Authority. He/She, has thus,, failed to perform his/her duty as the
Reporting Authority".

dd:
'a -da-
Place: SIGNATURE

auaod dddl dlQ ,5d.mdr

DATE NAME AND DESIGNATION

l{k-U-9-Cl{'s (lrrcLrlar
 -5-

wacJ-3-dd0
PART III REPORT
(dda drddrd erdoudo drdddeuddrdl)

1) €oiro *"r*ro
pdr&&d dodd qdrd aorlo rbead:r6d *dd*
Nature and quality of output with
reference to self assessment
po pa d po6-od
" 1
eo ea U eo dt6 {dc / eru {;il 7 ea 7

paqodsaeood dedl)
*(Out stand i n gA/ery good/Good/Average
Below Average)
't-o rto{ dBderod rborld) (rt/04
daderod rboc,Cdh g[d5eda-oer
dd!o0ddd6d3 *.f^ eeddtr * ddort
orj'sJdddo)
J'6Gl',
1-A -Targets fixed {Targets fixed shall be
specified separately and attached to the
Report)

2l uooir d*e@d ec{,3dcdrsd ilQ d0do6

Knowledge of sphere of work and skill
" ( eo po 6-ad ea 7 eo dr6 gid: / eru gid; 7 po 6-od sa 7
papodeae*od dedr)
*{Out StandingA/ery good/Good Average
Below Average)

3) d" dr:ood eoodriddordctood dgA{6ridc

Attributes covering the following aspects.
.:) dodd rc{ drdoetrod
Attitude towards work
* ( eo 6ro qro d co I eo dr6 Eidc / eru Eiil / UoGrod eo /
uoqodeaeuod dedl)
*{Out Standing/very good/Good Average
Below Average)

ts) wiloerBo daOdodgd CI{

Willingness to aasume Responsibility
eo pa6-od ea I eodr6 gid: / eru
,.
1 {dr go 6-od ea / 7

goqadeaeood dedr)
.{Out StandingA/ery good/Good Average
Below Average)
Rlt-E-9-CR's Circular
 -6-

&) 6!edd dq dr4 oloeoJpa Uodrd6r

Intiative and Planning abilitY
.i rpu WuO, / eedcdEdr / €'D gidr / Uoqad ea I
Paqodme.od dail)
*{Out standing/very good/Good Average
Below Average)

e) enrdgd drQ dogidJ

Zeal and lndustrY
<espapouea /erdr5$il/eru$dr/uoWadeo
I
goqadeos.oddadl)
*{Out standing /very good/Good Average
Below Average)

a) Patdd I
AccuracY
'r
( elpoqod-ea / el dl5{dc / uo gidl I UoOod e0 I
goqrodeae"od dail)
*{Out standing/very good/Good Average
Below Average)

,:f) $edrord ddrndod,rgd Uodld6r

Descision making abilitY
.
* ( eogo padm / eodc6gidc / eru giil / uouod m I

goqodme"od dail)
*(Out Standing /very good/Good Average
Below Average)

es) Ododeao d3d:eo6d{esmd d:Q dJamd dqrlC

d:ood ooepd5g)
Communication skill (Through words,
Written & Oral)
* ( eo go podm / udrdEdl / em$dl I uofod ea I

poqodeos"od dedl)
*{Out Standing/very good/Good Average
Below Average)

ds56) ddgd dgonqd PotcofrrSdc,

gledrao uodcd.St drd3 dodd dod
lnter-Personal relation,Motivation &
Team Work
* ( eo6ro ryod ea / d)dEdr / eru gidr / UoWad
Q, I ea

uepodeac.od da;b)
"{Out Standing/very good/Good Average
Below Average)

Rk-D-9 CR's Circular

 -7-

sc) ildrdodr ilQ dr:ooaC{ Uodl{5r

dreesoeuodrd
Supervision, Co-ordination and Leadership.
*( eo po p.od ea / g d:5{dl / em gidl / uo qrod ea /
popodeocod d6dl)
*{Out Standing/very good/Good Average
Below Average)

eJ) Uodrelpddooort doecod

Relation with the public

4) pd
Integrity
**{p{odo$ilod/dogoJDqd/pd egdodr agd/
gtudou fldldurlCg Ud?ss6o0ld)
**(beyond doubUdoubtfull / lack of integrity
proved in Disci pl inary/Cri m i nal proceedings)

5) dddeo
Training
*{puoro daddnb $rpoduoooJner dod Odrodel
eofiuorlul uooJordaodo dt{ md:d6rrldgtr
dqdeD ddeJs,So$ eocld6d)
(Need for training to further improve the
effectiveness and capabilities of the Govt.
servant)

6) eqreo dopdg ddod qrdsoidh

erudotoedrqdo$e r
Whether uses Kannada language
in official work.

7) go
erdoecl5
State of health
{padcdsuoer erdoerl5ddde eo@oo egde}
{Whether generally healthy or not}

8) oat*,o
Attendance
{urg*ouoodo$e Qedila @gds}
{Whether satisfactory or not}
.4.\-E-9-CR's C ircu lar
 . -8-

9) oa*rd5 #o5dadd
General assessment
* ( eopo podm / Qedr6E$ / eru$dl I uow-ad ra I
6roqodeac"od dail)
*{Out standing/Very good/Good Average
Below Average)

10) $eed PeBd

Grading
* ( eogo podeo / eo dl5$;tl / uugid: I uoWad eo I
dodl)
goqodeac"od
*( Out standing/Very good/Good Average
Below Average)
es{sd :

1. poidr-qUg UoeOAod ojrodlde Suo.Sisdoo frdds drQ e$aa douadd ddder

odtrdradtr?oug duod dcr, pord a{e6orrd1 oooersrd droerd ddrooddedr,
rbearlcdl d:Q
e. puoro daddort esuarodeo ged pearorl.elddg rldlp&d espo6od0o
eodd uaoJcr uoddo$iltr *.r^ esodd $ed peadrt uodeorlcdl do(sdejedr'

Note :
1. Adverse remarks and/oradvisory remarks should be indicated
as per rule 9 by
recording i specific note to thaieffect immediately below such remarks,

2. When a Government servant is graded outstanding the exceptional qualities.and

performance noticed as well as the grounds for such grading should be
indicated,

d/odd : {*} {**} eoQotuuorlde e$drddtr d/oddl 6"&0'

Note : {*} {r*} Strike' off whichever is not applicable'

€d' -So-
Place: SIGNATURE

dddl dc{ dduodr

NAME AND DESIGNATION
 \

-9-

elorr-4: dldtndeloedd
PART-IV:REVIEW

{arOo odetoedd ;SDdld Eiouod- drodcJeuodldl}

{ To be made by the Reviewing Authority}
1. Pdd €olro diaer5drodd dr*
ddo dradrd goddd ddoodrilh
ped s,qgso"? s.,{Oqg erdd" uodeor,Cdtr peo.
Whether self assessment and the
reports of the reporting authority
is acceptable. if not ,give reasons

2, dldd eodeloedd drodd il3ouodd duodCl

oJndoadda @qg?
Remarks of the Reviewing Authority, if any

rs{d :
t. potrdr-gdg doo&dod oJmdrde duo $odoo frdde il{ e$oa $ouad,d ddde r
odldradtr oodd duod dgrt pot* rs{rdoltdtr roerodrd dmod ddraoddedl.
z. duaro Eddort elpouodeo $eed peauorl.oddg rrdrppd eopooodea r$oorlCdtr ilQ
esdd uooiruoddo$dra oarto oodd gled peadrt uodearlCdtr doodeJea:.
s. doBeouo €o6od qorl-z dpd 'd,acdd"o$dt .t*rppd-d"q odr * $ddea{
eo{ol:oadg {esodd,* $ddeodg ddO drodqdtd duoro Pdd$ do dradrd
F3oerodilodg uorto oddl oeg uo&rd ddootda ecdogdodl ?FTdrJ-zdg goe6pdg )
eo ddod, g[,3doo *uodd,] deoildd"de.

NOTE:
1. Adverse remarks and / of advisory remarks should be indicated as per rule 9 by recording a
specific note to that effect.immediately below such remarks.
2. When a Government servant is graded outstanding the exceptional qualities and performance
noticed as well as the grounds for such grading should be indicated.
3. The Reviewing Authority shall refer to the "lnstruction" contained in Part- ll. ln case it is
applicable to this case, {that is, the Government servant reported upon in this repoft is a
Reporting Authority and has declared in Part- ll, that he has not written all the Annual
Performance Reports), an adverse remarks shall be entered accordingly"

dd:
'a -do-
Place: SIG,NATURE

dddr dcd2 ddgodr

NAME AND DESIGNATION
 -10-

f;torJ-o esooeuad
PART.V ACCEPTANCE'
'
{tooodo&d gouodaod}
(By the AccePting AuthoritY)

'1. sroJBd duorJCl : eogeqo$

Remarks on the whole

es{r6 : (1) pofrdr-edg does&dod ofodrde doa dodDo frdder dlQleodo-o

deruadud ii*s r adtrdrddl eoodd duod dCrt
pot{ rs{e6otdtr
craoerdld droeld ddroodcJe&.

(2) duoo daddort ugorodeo gesd peardrl erddg dilp&d

eogo6-odea rrlearlcdl d:Q eldd uoodrrgodddldh dartro esodd
g[ee6 peadrt uodearlCdtr doteileJe&.

Note : 1. Adverse remarks and/or advisory remarks should be

indicated as Per rule 9 by recording a specific note to
that effect immediately below such remarks,

2. When a Government servant is graded outstanding the

exceptional qualities and performance noticed as well
the grounds for such grading should be indicated.

dd:
'a -da-
PIace: SIGNATURE

aUood: dddr ild2 ddgo;n

DATE: NAME AND DESIGNATION

I(k-E-9-CR's CircLrlar
 -11-

o10r,-6: doddd (@qg)

PART.VI GOMMUNICATION (IF ANY)

1 (o) go*oer'duorJ$ oJrodroaddo e{d

odrlCdtr ssderod
d$d doeJ5 ilQ oPaod.
1(A) Reference No and date of
communication of adverse remarks

1(rc) gouadrd fiuorl$ odroduoddo edd.

eodrclCdtr ,gtrrud
d$d Poel6 dr{ osood.
1(B) Reference No and date of
communication of advlsory remarks,
if any

2 olm{roddo dlds ccoo{d .5ila

qsdo8,d ouood
2 Date on which rePresentation,
if any received

3 ;trdso$ d:eerd pmrodr dtQ eoddtr

poeloddq duoro daddort,Str&d Ogood
3 Decision on representation and date of
Communication to the concerned
Govt servant

4 eoepdd*dPrl dCla,rrd "oP'ood

4 Date of having forwarded to the custodian

'.a
-do-
Place: SIGNATURE

,:ta;ac-rd :
dpdr drQ ddPadc
DATE :
NAME AND DESIGNATION

lll. I -'l CI{-s Circtrlar

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