STATE OF GEORGIA

PERFORMANCE MANAGEMENT FORM

Employee Name: Katrina Jones Emp. ID #: Job Title: Community Support Worker
Manager Name: Tiffany Green Department: Day Program
Review Period: From: 01/17/17 To: 06/30/17
What Sections will you be using in your evaluation?
All Sections (1, 2 and 3) Users must click on the drop down arrow to the left of this field to select which form sections will be included in the overall rating.
Score the performance in each job factor below on a scale of 5-1 or N as follows:
5 = Exceptional Performer Employee exceeded all performance expectations. Employee was an exceptional contributor to the success of his/her
department and the State of Georgia. He/she demonstrated role model behaviors.

4 = Successful Performer-Plus Employee met all and exceeded most (more than 50%) of the established performance expectations.

3 = Successful Performer Employee met all performance expectations and may have exceeded some (less than 50%). Employee was a solid contributor
to the success of his/her department and the State of Georgia

2 = Successful Performer – Minus Employee met most (more than 50%), but failed to meet some performance expectations. Employee needs to further improve
in one or more areas of expected job results or behavioral competencies.

1 = Unsatisfactory Performer Employee did not meet all or most (more than 50%) of the established performance expectations. Employee needs significant
improvement in critical areas of expected job results or behavioral competencies.

N = Not rated: At the agency’s discretion, a new hire or transfer within five months of the end of the performance period may or may not
receive a performance rating.

Section 1: Individual / Core Competencies (25% minimum of total score)

Core Competencies (All Employees) Comments Rating
Customer Service - Understands that all employees have customers, internal and external, Has met. Treats all clients that are provided a service here at the
that they provide services and information to; honors all of the State’s commitments to Center the latest information that is given to uphold all State
customers by providing helpful, courteous, accessible, responsive, and knowledgeable service. regulations. 3

Teamwork and Cooperation - Cooperates with others to accomplish common goals; works Has met. Works will with her co-worker that is in the same dept.
with employees within and across his/her department to achieve shared goals; treats others sharing information & working together for the common goal of
with dignity and respect and maintains a friendly demeanor; values the contributions of others. serving the clients of TGSC. 5

Results Orientation - Consistently delivers required business results; sets and achieves Has met.
achievable, yet aggressive, goals; consistently complies with quality standards and meets 4
deadlines; maintains focus on Agency and State goals.

DOAS Human Resources Administration 1 Revised 10/2012

Accountability - Accepts full responsibility for self and contribution as a team member; Has met.
displays honesty and truthfulness; confronts problems quickly; displays a strong commitment to
organizational success and inspires others to commit to goals; demonstrates a commitment to 5
delivering on his/her public duty and presenting oneself as a credible representative of the
Agency and State to maintain the public’s trust.

Judgment and Decision Making - Analyzes problems by evaluating available information and Has met in bringing forth problems that have been encountered while
resources; develops effective, viable solutions to problems which can help drive the on the job. 4
effectiveness of the department and/or State of Georgia.

Leadership Competencies (people managers & other leaders) Comments Rating

Talent Management - Clearly establishes and communicates goals and accountabilities;
monitors and evaluates performance; provides effective feedback and coaching; identifies
development needs and helps employees address them to achieve optimal performance and 3
gain valuable skills that will translate into strong performance in future roles.

Transformers of Government - Develops, recommends, or implements innovative

approaches to address problems and drive continuous improvement in State programs and
processes; drives effective and smooth change initiatives across the State by communicating, N
confirming understanding and activity working with stakeholders to overcome resistance.

Other Behavioral Competencies Comments Rating

Community Outreach: Discover & share new community connections while being out in the The radio station - collabortative w/ Deri Small - 730 AM. Gospel
community to assist with finding new contacts/opportunities that can be brought back to the Station, Willow water company, Clanton's Veterinary 4
Center for the benefit of the individuals.

Note: Calculate the overall section rating by adding the ratings for the individual items in the Overall Section Rating:
section, and then by dividing that total by the number of items in the section.
4.0
Section Weight (not less than 25%): 25%

DOAS Human Resources Administration 2 Revised 10/2012

Section 1: Overall Comments:

Section 2: Individual Goals (Weighting can range from 0% to 75% of total score)

Comments Rating
Goal 1: Make 3 Community Connections within the course of the year to bring back to the Bethany Hospice, YMCA Bingo, Flowers Bakery Tour
Center for the benefit of the individuals to introduce them to more things within their 50
community.
Goal 2:

Goal 3:

Goal 4:

Goal 5:

Note: Calculate the overall section rating by adding the ratings for the individual items in the Overall Section Rating:
section, and then by dividing that total by the number of items in the section. 5.0
Section Weight: 50%
Section 2: Overall Comments:

DOAS Human Resources Administration 3 Revised 10/2012

Section 3 – Job Responsibilities (Weighting can range from 0% to 75% of total score)

Comments Rating
Job Responsibility 1: Provide Direct Well-Designed Training that present opportunities 1) Has been doing well in making sure the UB is being reflected
for the Participants to have a Valuable Day while in the within the individuals' ISP. 2) Has met. Services have been
Community: (1). Actively involve Individual's in training or leisure designed to meet client's preferences. 3) Needs work on making
sure that documentation is being made on monitoring
activities during scheduled times and training must be reflective of the
individuals progress & note specifics. 4) Just be mindful to
person's Individualized Service Plan (ISP) & Person Centered; (2). ignore the bad behavior & promote good/positive behavior,
Services are individually designed to meet the participant's needs redirection is appropriate while out in the community. 5) Have
and preferences.; (3) Monitor Individual's progress during training met, by using age appropriate activities to experience. 6) Have
and note specifics relative to progress (improvement, tolerence, met. 7) Have met.
enjoyment, body language, and verbal expressions); (4). Implement
Proactive Measures to Promote Positive Behaviors (presenting
options and activities that interest the person) and Interact with
Individuals using Only Positive Reinforcement (Reward Good 9
Behavior & Ignore Bad Behavior); (5). Use age-appropriate
interaction/activity designed to promote dignity, respect and
independence; (6). All services must be provided off Thomas Grady
Service Center campus or other service sites to be considered
Community Supports 1:1; (7). Provide supervision at all times to
ensure participants safety while in the community (0 tolerance of
neglect). (Report All Progress to Supervisor).

Job Responsibility 2: Complete Documentation of Assigned Individual's accurately Has been doing well with documentation & documenting on
and in a timely manner (according to policy and procedure): (1). training the individual is acquiring while out in the community,
Document using appropriate instruments/forms (Seizure, Behavior, saying in the note whether he is needing more help, hand over
hand, verbal prompt, or independence…working on specific
Fluid and Bowel Elimination, Incidents, Attendance, Observation and
goals i.e. cashing checks, ordering food in restuarant, making
Progress Report); (2). Record all units accurately; (3). Document independent purchases.
progress of all assigned individuals including (increase or decrease in 11
progress, body language and verbal expressions) what training did
the individual accuire while out in the community; was the individual
able to grasp what was being trained and (4). Knowledgeable of all
Instruments/Forms and their location. (Report All Progress to
Supervisor).

Job Responsibility 3: Lead Unit Monitor: (1). Review all Progress Reports to check Has done very well with this job responsibility in giving a variety
accuracy of units; (2). Tally all units and report results to supervisor. of different places to choose from with the client's i.e. places to
(3). Assist the participant in acquiring, retaining, or improving self- eat that individuals may have never been too or thought of
trying b/c they didn't know that they could.
help, socialization, and adaptive skills. (4). Make opportunities for
individuals to Explore and Experience enough times that they will be 10
able to consciously decide if they like or dislike the experience, (1 to 2
times are most often not enough). (Report All Progress to
Supervisor).

DOAS Human Resources Administration 4 Revised 10/2012

Job Responsibility 4: Assure health and welfare of individual served at all times while 1) Has done very well w/ personal care, assisting with client's
in the community: (1)Personal Care—Helps consumers with that have a hard time toileting, helping those on & off the van
eating, grooming, dressing, bathing, and toileting; assists Individuals with unsteady gait & with wheelchairs/walkers. 2) Handling
money of the individuals that are given prior to an outing.
with their mobility including lifting them from a seated or lying down
Cleans up behind herself & the client when using the Center's
position, helping them walk and maintain stability; (2)Operational vehicle. Brings in receipts when money is left over from outing
Support—Maintains cleanliness of program; drives company vehicle to account for what was spent on outing. 3) Informing
to transport Individuals to their activities; completes tasks that are supervisor of injuries or falls, when eye sight is failing, & other
beyond the Individual’s abilities; follows policies and procedures for difficulties client's are having while out in the community.
handling money. (3). Stay Abreast of Client Progress - Recognize
and communicate any environmental changes or unusual
11
occurrences; Recognize and address an incident or problem behavior
that requires intervention; Familiarize themselves with each
consumer’s standard lifestyle and baseline level of functioning;
Continually assess a consumer’s status and needs; Follow program
procedures in addressing unusual occurrences and problem
behaviors; and Document all findings in program records. (Report
All Progress to Supervisor).

DOAS Human Resources Administration 5 Revised 10/2012

Job Responsibility 5: Community Access Individual services provided to an individual 1) Have met - w/ TGSC transportation, vans given & kept up with
under covered services: (1). Provide necessary transportation to mileage, along with the use of employee's personal vehicle
and from the approved activity(s). Note: Transportation provided is when vans were not available. 2) Have met. 3) Have met - when
helping individuals pay out for services rendered, i.e. eating out,
included in the cost of everyday business hours and is
purchasing something at the store. 4) Have met. 5) Needs
incorporated in the adminstrative overhead cost; (Never ask improvement - work on for next quarter meeting with individuals
participants for money for transportation in the event that your prior to outing to somewhat plan the UB outing & discussing
are driving your personal vehicle). (2). Unit of service: 15 minutes. with the individual options & places of interests that they would
(3) Provide necessary supports to individuals to experience like to visit after goal has been tracked. 6) Have met - 5 days
resources, i.e. (physical supports, verbal supports, demostrations, prior to getting letter out to families & home provider timely. 7)
and observations to ensure no other supports are needed). Note: Have met, some cases where it can't be helped do to some
Participants are responsible for paying for their own interested switching around with schedule b/c individual has declined or is
services or experiences such as; purchasing items in a store, absent from Center on the day of UB outing. 8). Have met. 9)
Have met. 10) Haven't met yet - but needs to start happening to
going to a movie, having a beauty day, joining a club or let the SW know of new possible goals of interests for the up-
organization. (If the person cannot afford the opportunity, coming ISP. 11) Have met yet - no cases at this time.
scholarships can be requested by them or on their behalf). (3).
Complete Progress Note on each individual incorporating all areas of
the training supported while out on an outing. (4) Work with
participants on planning the outing to reflect what is current in the ISP 9
along with implementing having it personed centered (5). Complete
outing form 5 days prior to planned trip. (6). Ensure that if
participants' need money for outing it will need to be collected within
no later than 2 days prior to outing. (7). Ensure that all other supports
are in place for the individuals being taken out on monthly schedule
prior to going out. (8). Provide a monthly schedule for supervisor by
no later than the last Monday within the current month upon entering
into the following month. (9). Required to work professionally with
other staff/team members on developing new goals and advocating
for individuals during ISP staffings. (10) Report any possible evidence
of abuse or neglect of individual to Supervisor immediately when
suspected.(Report any questions to Supervisor for clarification
when in doubt).

DOAS Human Resources Administration 6 Revised 10/2012

Note: Calculate the overall section rating by adding the ratings for the individual items in the Overall Section Rating:
section, and then by dividing that total by the number of items in the section. 5.0
Section Weight: 50%
Section 3: Overall Comments:

DOAS Human Resources Administration 7 Revised 10/2012

Section 4: Employee Comments

Section 5: Manager Comments

Section 6: Overall Rating

Section 1 Rating: 4.0 Section 1 Weighting: 25% Weighted Rating Section 1: 0.0
Section 2 Rating: 5.0 Section 2 Weighting: 50% Weighted Rating Section 2: 0.0
Section 3 Rating: 0.0 Section 3 Weighting: 25% Weighted Rating Section 3: 0.0
Note: Calculate the overall rating by multiplying the ratings for each section by the weighting OVERALL RATING:
for each section. This will give you the weighted ratings for each section. Add the weighted 0.0
ratings together for the overall rating.

Key Accomplishments for Review Period

Section 7 - Individual Development Plan (not rated or weighted)

Comments
Development Action 1:

Development Action 2:

Development Action 3:

Development Action 4:

Development Action 5:

DOAS Human Resources Administration 8 Revised 10/2012

Signatures

Employee Signature: Date:

Supervisor/Manager: Date:

Reviewing Manager: Date:

DOAS Human Resources Administration 9 Revised 10/2012

Which sections will you be using?
All Sections (1, 2 and 3)
Sections 1 and 2
Sections 1 and 3