STATE OF GEORGIA

PERFORMANCE MANAGEMENT FORM

Employee Name: Precious Dean Emp. ID #: Job Title: Direct Support Client Supervisor
Manager Name: Tiffany Green Department: Day Hab - Building B
Review Period: From: 07/01/17 To: 06/30/18
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, Shows professionalism when dealing with outside customers, greets
that they provide services and information to; honors all of the State’s commitments to all those that walk in the door, helps in calling other agencies,
customers by providing helpful, courteous, accessible, responsive, and knowledgeable service. parents/providers when problems arise or information is needed 4

Teamwork and Cooperation - Cooperates with others to accomplish common goals; works Team work has improved greatly within the dept. Jumping to cover
with employees within and across his/her department to achieve shared goals; treats others when a CSW is out and coverage is needed within the classroom
with dignity and respect and maintains a friendly demeanor; values the contributions of others. setting has been benefical. Helping during ISP prep to create new 5
goals that are person-centered and valuable to the individual.

Results Orientation - Consistently delivers required business results; sets and achieves Completes all required manatory trainings required by the center.
achievable, yet aggressive, goals; consistently complies with quality standards and meets (Relias) Completes all required TGSC trainings throughout the year
as directed. 3
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;
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
delivering on his/her public duty and presenting oneself as a credible representative of the
Agency and State to maintain the public’s trust.
Areas of focus - mindful of leave balance so not to go over when
things come up which are uncontrollable that have to be out for. Work
on becoming stronger in commitment to goals within the dept that
need to be done as a supervisor - organizational skills. Does a great 3
job at being a good representative of Agency when out in the public.

Judgment and Decision Making - Analyzes problems by evaluating available information and Does well in the daily decision-making for the benefit of the dept.
resources; develops effective, viable solutions to problems which can help drive the Consult Dept manager when there is an issue with outside agency 4
effectiveness of the department and/or State of Georgia. that concerns individual's health & safety.

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
gain valuable skills that will translate into strong performance in future roles.
Works well with others within the dept. Makes sure that everyone is
on the same page when new things are implemented. Will lend a
helping hand with the dept is short inside the classrooms, work on
helping in times of contract work if staff is overwhelmed with a larger 4
load then normal so productivity is kept up.

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,
confirming understanding and activity working with stakeholders to overcome resistance.
On board with changes that comes from Day Hab Director to help
execute within the dept. Offers suggestions & ideas to Day Hab
Director in trying to make dept run more successful.
3

Other Behavioral Competencies Comments Rating

Leadership Growth Training Completed POM Training
5

31/8
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.
3.8
Section Weight (not less than 25%): 25%

DOAS Human Resources Administration 2 Revised 10/2012

Section 1: Overall Comments:
Extemely proud of you completely POM training with me. I would like for you to complete more trainings for the next year if allowed for more continued growth for the dept. Keep up the good
work. Continue to stay organized, focused, and consistent in making sure that the CSW that you supervise are doing everything that they are suppose to do and your not having to carry the
load. I would like to see you training them and helping them understand why the center does what it does, why it is necessary for PA's, SIS, Person-centeredness, creating Right's Training that
the individuals can retain for purposes of CQL/Qlarant reviews, why we must track & log behavioral issues...all are a means to an end for the benefit of the individual that we are serving here at
TGSC.

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

Comments Rating
Goal 1: Community Connections: plan and carry out community access activities that will The activity/experience can be CAI or CAG, but if it's CAG in the
involve the participants of Day Hab as well as the other individuals that attend the community, two or more staff would be with a group at a ratio of 2:6
agency in new and challenging experiences. Be creative, study a person's ISP and or at some point CAI would be provided to each participant with one
staff remaining in with the group while the other staff will provide 1:1
come up with new ways to have individuals more involved in their communities that
CAI.
focuses on person-centered. In order for an activity to be considered "exceptional",
it will meet the following criteria: 1) It must be novel for the individual. Not
necessarily new, but designed to challenge and teach. 2) Related to the current 0
ISP. 3)The experience provides something new learned that can be decumented in
the notes. (Photos and videos are encouraged). 4) If the experience will happen
here, some part of the community comes in with us and a good portion of the
participants benefits.

Goal 2: Continue with more Leadership Training to promote growth FY 19-20

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.
Section Weight: 15%

DOAS Human Resources Administration 3 Revised 10/2012

Section 2: Overall Comments:
Need to increase community connections while out covering UB's. I would like to see if next year will allow for you to attend a leadership training in some capacity that will promote growth that
you can bring back to the Dept.

DOAS Human Resources Administration 4 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 Areas of Focus- pay close attention to PA's that have come out for
for the Participants to have a Valuable Day: (1). Actively involve new ISP to make sure units are being correctly covered wkly/mnthly.
Individual's in training or leisure activities during scheduled times and Does a great job in promoting and using age appropriate interactions
& activities. Work closely with the assigned staff that you supervise to
training must be reflective of the person's Individualized Service Plan
develop meaningful trainings.
(ISP); (2). Monitor Individual's progress as well as assigned staff
daily during training and note specifics relative to progress
(improvement, tolerence, enjoyment, body language, and verbal
expressions); (3). Impliment Proactive Measures to staff in order to
Promote Positive Behaviors (presenting options and activities that
interest the person) and Interact with Individuals using Only Positive
Reinforcement (Reward Good Behavior & Ignore Bad Behavior); (4). 4
Use age-appropriate interaction designed to promote dignity, respect
and independence; (5). Help staff develop weekly Lesson Plans and
use as a guide for daily lessons and make available when request is
made to see how Individuals have been engaged and (6). Provide
training room supervision at all times to ensure participants safety
when staff are called out of the training room (0 tolerance of
neglect). (Report All Progress to Day Hab Director).

Job Responsibility 2: Complete Documentation of Assigned Individual's accurately
and in a timely manner (according to policy and procedure): (1).
Making sure that assigned staff document using appropriate
instruments/forms (Seizure, Behavior, Fluid and Bowel Elimination,
Incidents, Attendance, Observation and Progress Report); (2).
Record all units accurately; (3). Document progress of all assigned
individuals including (increase or decrease in progress, body
language and verbal expressions); and (4). Knowledgeable of all
Instruments/Forms and their location. (Report All Progress to Day
Hab Director).
Areas of Focus - making sure that assigned staff that you supervise
are completing all the necessary paperwork, reports and filing in
correct place. Improving in documenting incidents, discovery of
bruising & behaviors in a timely manner. (Placing in Therap or Log
Books kept in-house/ Daily Seizure Logs for those that have Seizure
D/O & BSP). Progress notes tell about the individual being person-
centered and shows progress of the individual when successes are 3
being met.

Job Responsibility 3: Lead Unit Monitor: (1). Review all Progress Reports to check
accuracy of units; (2). Tally all units and report results to supervisor.
(3) Monitor assigned staff documentation to ensure that an accurate
progress note is wrote on the correct goal. (Report All Progress to
Day Hab Director)
Does will in keeping up with the progress notes and making sure that
if an incorrect note is place needs to be taking out. Calls and speaks
with Darrell if they is an issue regarding a note in Therap.Areas of
Focus- implementing & improving that we are keeping track & having
4
a better system of weekly units so Dept is not missing units or going
over unneccesarily.

DOAS Human Resources Administration 5 Revised 10/2012

Job Responsibility 4: Assure health and welfare of individual served at all times: Helps monitor to make sure that individuals attending the day
(1)Personal Care—Helps consumers with eating, grooming, program are taking care of by doing instructional trainings that
dressing, bathing, and toileting; assists Individuals with their mobility promote independence. Monitors changes within individuals if there is
a behavioral change, physically change, knows their baseline of level
including lifting them from a seated or lying down position, helping
of functioning.
them walk and maintain stability; (2)Operational Support—
Maintains cleanliness of program; drives company vehicle to
transport Individuals to their activities; completes tasks that are
beyond the Individual’s abilities; follows policies and procedures for
handling money. (3). Stay Abreast of Client Progress - Recognize
and communicate any environmental changes or unusual
5
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 Day Hab Director).

Job Responsibility 5: Daily Direct Support Client Supervisory tasks1) Supervising Areas of Focus- work closer with assigned staff to make sure that
assigned staff designated by DH Director. 2) Coordinating with other they are completing areas of trainings, BSP documentation, HRST
direct support client supervisor in taking AL. 3) Making sure that trainings timely, productivity sheets are filled out properly.
HRST trainings are completed 30 days after individuals birthday that
are assigned to caseload. 4)Working with other supervisor to resolve 4
conflicts that effect daily operation. 5) Collaborate with other
supervisor to ensure UB, Work, & Fri lunch are being rotated
amongst staff on a monthly calendar.

Cont. 6) Ensuring that classroom training ratio is balanced among

staff within training classroom. 7) Make documentation in the event
that a write up needs to be completed on assigned staff for infraction.
8) Ensuring that assigned staff give adaquate time frame to request
time off. 9) Help staff monitor and document displayed behaviors from
those individuals that have BSP & those individuals that may need
one. 10) Ensure supervisor's assigned staff that weekly timesheets
are filled out properly using the correct leave. 11) Ensure that
productivity sheets are filled out correctly by assigned staff and
turned in weekly.

DOAS Human Resources Administration 6 Revised 10/2012

 20/5

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. 4.0
Section Weight: 60%
Section 3: Overall Comments:
Great Job! Continue to keep up the good work. You are a valuable asset to Day Hab & TGSC!

DOAS Human Resources Administration 7 Revised 10/2012

Section 4: Employee Comments

Section 5: Manager Comments

Section 6: Overall Rating

Section 1 Rating: 3.8 Section 1 Weighting: 25% Weighted Rating Section 1: 1.0
Section 2 Rating: 0.0 Section 2 Weighting: 15% Weighted Rating Section 2: 0.0
Section 3 Rating: 4.0 Section 3 Weighting: 60% Weighted Rating Section 3: 2.4
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 3.4
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