Interim Evaluation Form

This form is designed as an instrument for supervisors to use when meeting with non-probationary employees for performance evaluation other than the annual review. Supervisors are encouraged to provide periodic evaluations for each employee. A
six-month evaluation is not required. The six-month evaluation may be submitted to Human Resources, with copies retained for the supervisor’s files and for the employee. Any other interim evaluation forms should be kept in the supervisor’s file.

Employee Name:	Employee ID #:
Department:	Date prepared:

Core Responsibility	Rating/Comments
Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor
1
Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor
2
Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor
3
Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor
4
Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor
5
Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor
6

(Attach separate sheet for additional expectations)

Special Assignments	Rating/Comments
Brief description of assignment(s)	Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor

Departmental Values	Rating/Comments
Below Contributor Moderate Contributor Contributor High Contributor Extraordinary Contributor

Overall Rating Earned To Date
Extraordinary Contributor Acknowledgement of Extraordinary Contribution form or Written Notice on file?	Performance shows sustained, exemplary accomplishment throughout the rating period. Performance is well above the criteria of the job function. (At least one Acknowledgement of Extraordinary Contribution must be on file in supervisor’s departmental file.)
High Contributor	Performance shows a consistently high level of accomplishment, often exceeding performance targets.
Contributor	Performance shows consistent achievement toward meeting established performance expectations.
Moderate Contributor	Performance shows inconsistent achievement toward meeting minimum standards for the position. Expectations were not met consistently and further development is required.
Below Contributor* Notice of Improvement Needed form on file? Specific Improvement Plan attached?	Performance shows deficiencies that interfere with the attainment of performance expectations. (At least one Notice of Improvement Needed form (or Written Notice) must be on file along with a specific improvement plan.)

Supervisor’s Signature:	Date:
Supervisor’s Name Printed:	Employee ID #:
Employee’s Signature:	Date:
Employee’s Name Printed:	Employee ID #:
Reviewer’s Signature: (optional)	Date:
Reviewer’s Name Printed:	Employee ID #:

*Below Contributor - An employee cannot receive a rating of Below Contributor unless the immediate supervisor has completed a Notice of Improvement Needed form and an improvement plan or issued a Written Notice prior to this Interim Evaluation Form. The Improvement period should be no less than 30 days or no more than 180 days. The supervisor and the employee should develop the improvement plan together, but if an agreement cannot be reached, the supervisor may establish the improvement plan on his or her own. The improvement plan must be signed by the employee and supervisor and must be signed by the reviewer.

Interim Evaluation Fact Sheet

Purpose of the form:

The Interim Evaluation Form is used to evaluate and assess a non-probationary employee’s progress toward achieving the core responsibilities of the position during the performance cycle and to document performance problems.

When the form is prepared:

Interim evaluations may be conducted at any time during the performance cycle. However, an interim evaluation for non-probationary employees at the mid-point of the performance cycle is usually the best time to complete it.

The form is also completed when personnel changes occur during the evaluation cycle. A supervisor who leaves during the performance cycle should complete an interim evaluation of the employee’s performance prior to departing. If an employee transfers, is promoted or demoted into a new position with a different supervisor within an agency or between agencies, an interim evaluation should be completed.

Who prepares the form:

The immediate supervisor completes the Interim Evaluation Form and discusses the progress toward achieving core responsibilities with the employee. Both the supervisor and the employee sign the form. The reviewer’s signature is optional.

Presentation of the form:

A copy of the Interim Evaluation Form is given to the employee.

Retention:

A six-month evaluation may be submitted to Human Resources. Provide a copy of the signed document to the employee. Retain a copy of the signed document for departmental records.

Whom to Contact:

For more information or clarification, contact an HR Consultant.