Republic of the Philippines

Department of Health
Center for Health Development 2
REGION II TRAUMA AND MEDICAL CENTER

ISO 9001:2015 Certified

To the Applicant:
Please accomplish the first part of this form and give it to your supervisor, former professor or any
person (other than your relatives) who knows you well enough to be able to fill it out in a manner that
will help the Human Resource Merit Promotion and Selection Board (HRMPSB).
Provide each person making this evaluation with an envelope addressed to the:
THE SUPERVISING ADMINISTRATIVE OFFICER
Human Resource Management Office
Veterans Regional Hospital
4/F, OPD Building, Brgy. Magsaysay
Bayombong, Nueva Vizcaya

Write the rater’s name and address on the upper left side of the front of the envelope.
Please submit the sealed and signed envelope on or before ___________________.

To the Rater: __________________________________

(Applicant to fill in the appropriate name )

The applicant named above is applying for the position as ______________________. ( Indicate
position applied for)
Kindly give your honest appraisal of the applicant’s abilities and qualification for the said position.
Your evaluation of the applicant’s major strengths and weaknesses (e.g. organizational commitment,
integrity, stewardship of resources, teamwork, and quality service focus) and his/her moral fitness
would be very helpful to us in considering the applicant.
The information supplied in this form will be treated confidentially and will be used only for the purpose
of assessing the applicant’s qualifications for inclusion in the selection process.
Enclose the filled-up form in the envelope provided, seal the envelope, affix your signature across the
flap and return it to the applicant. If you prefer not to send your evaluation through the applicant, you
may send it directly to the address mentioned above. Please note that his/her application will be
evaluated only after receipt of all required documents, including this evaluation.
 Republic of the Philippines
Department of Health
Center for Health Development 2
REGION II TRAUMA AND MEDICAL CENTER

ISO 9001:2015 Certified

Annex D

EVALUATION FORM
SUPERVISOR / FORMER PROFESSOR
(For First and Second Level)

Name of Applicant : ________________________________________________

Present Position and Office/Unit : ________________________________________________
Position Applied for : ________________________________________________
Location / Office / Unit : ________________________________________________

X---------------------------------------------------------------------------------------X

INSTRUCTION: Encircle the rating that appropriately describes the applicant’s performance based on
your personal observation and assessment. The evaluation scale has five (5) ratings, 5 belong to the
highest and 1 the lowest.

A. ORGANIZATIONAL COMMITMENT – Identifies one’s behaviour with the organization’s vision,

mission, and goals and strives to realize the same.
Key Behaviours:
 Exhibits loyalty and commitment to the organization;
 Day to day activities reflect or embody the vision, mission and goals of the organization;
 Explain to clients, partners and stakeholders what make up the thrusts, core functions and
programs of the DOH

5 4 3 2 1

B. INTEGRITY – observes social, ethical and organizational norms in all work-related activities.
Key Behaviours:
 Takes full responsibility for actions, admits mistakes and makes effort to correct or set things
right.
 Exhibits decency in actions and words and earns the respect of co-employee and superiors.
 Behaves in accordance with moral and ethical standards.

5 4 3 2 1

C. STEWARDSHIP OF RESOURCES – ensures that operations produce desired results within

available resources.
Key Behaviours:
 Observes efficiency, economy, and due care/diligence in the use of resources.
 Ensures equitable and prompt distribution of resources.

5 4 3 2 1
 Republic of the Philippines
Department of Health
Center for Health Development 2
REGION II TRAUMA AND MEDICAL CENTER

ISO 9001:2015 Certified

D. TEAMWORK – Participates as part of a team and works in union towards the attainment of
organizational goals.
Key Behaviours:
 Supports group’s decision, acts in solidarity and believes in mutual assistance and cooperative
effort.
 Provides supportive environment based on trust, respect and commitment;
 Accepts individual differences and subordinates or yields personal prominence or credit to
group performance and efficiency.

5 4 3 2 1

E. QUALITY SERVICE FOCUS – Provides quality service and ensures client satisfaction through
continuous improvement / enhancement of policies and procedures.
Key Behaviours:
 Monitors accuracy and quality of work and takes immediate action to correct mistakes.
 Attends to client’s inquiries and complaints promptly, courteously and with compassion;
 Monitors client’s satisfaction by obtaining feedback.

5 4 3 2 1

Comments and recommendations, if any

____________________________ ____________________________

(Signature Over Printed Name) Date

Annex D
 Republic of the Philippines
Department of Health
Center for Health Development 2
REGION II TRAUMA AND MEDICAL CENTER

ISO 9001:2015 Certified

EVALUATION FORM
PEER / SUBORDINATE
(For First and Second Level)

Name of Applicant : ________________________________________________

Present Position and Office/Unit : ________________________________________________
Position Applied for : ________________________________________________
Location / Office / Unit : ________________________________________________

X---------------------------------------------------------------------------------------X
INSTRUCTION: Encircle the rating that appropriately describes the applicant’s performance based on
your personal observation and assessment. The evaluation scale has five (5) ratings, 5 belong to the
highest and 1 the lowest.

A. ORGANIZATIONAL COMMITMENT – Identifies one’s behaviour with the organization’s vision,

mission, and goals and strives to realize the same.
Key Behaviours:
 Exhibits loyalty and commitment to the organization;
 Day to day activities reflect or embody the vision, mission and goals of the organization;
 Explain to clients, partners and stakeholders what make up the thrusts, core functions and
programs of the DOH

5 4 3 2 1

B. INTEGRITY – observes social, ethical and organizational norms in all work-related activities.
Key Behaviours:
 Takes full responsibility for actions, admits mistakes and makes effort to correct or set things
right.
 Exhibits decency in actions and words and earns the respect of co-employee and superiors.
 Behaves in accordance with moral and ethical standards.

5 4 3 2 1

C. STEWARDSHIP OF RESOURCES – ensures that operations produce desired results within

available resources.
Key Behaviours:
 Observes efficiency, economy, and due care/diligence in the use of resources.
 Ensures equitable and prompt distribution of resources.

5 4 3 2 1
D. TEAMWORK – Participates as part of a team and works in union towards the attainment of
organizational goals.
 Republic of the Philippines
Department of Health
Center for Health Development 2
REGION II TRAUMA AND MEDICAL CENTER

ISO 9001:2015 Certified

Key Behaviours:
 Supports group’s decision, acts in solidarity and believes in mutual assistance and cooperative
effort.
 Provides supportive environment based on trust, respect and commitment;
 Accepts individual differences and subordinates or yields personal prominence or credit to
group performance and efficiency.

5 4 3 2 1

E. QUALITY SERVICE FOCUS – Provides quality service and ensures client satisfaction through
continuous improvement / enhancement of policies and procedures.
Key Behaviours:
 Monitors accuracy and quality of work and takes immediate action to correct mistakes.
 Attends to client’s inquiries and complaints promptly, courteously and with compassion;
 Monitors client’s satisfaction by obtaining feedback.

5 4 3 2 1

Comments and recommendations, if any

____________________________ ____________________________

(Signature Over Printed Name) Date