QUALIMED MANILA

PERFORMANCE APPRAISAL FORM (PROJECT BASED EMPLOYEES)

Employee Being Reviewed: Please complete the Self Evaluation portion of this review by checking column
corresponding to the numeric description. When complete, submit it to your Department Head.
Employee Name: Emp. Nos.

Project Site:

Evaluation Period:

Evaluated By: Date:

Supervisors Name/Signature

Rating Review By: Date:

HR Representatives Name/Signature

Department Head Conducting Review: Complete the Department Heads Evaluation by checking the column
corresponding to the numeric description of the job holders level. Compute for the rating by dividing the raw score
to percentage (e.g. 5 x 0.4 for 40%), then add all the scores to get the total points earned.

GOALS TARGET Self EVALUATION Department Heads

EVALUATION
1 2 3 4 5 1 2 3 4 5
Clinic Administrator (20%)
(Attendance and Sickness Management, File Management,
Stock Medicine Inventories, Issue Health and Safety
Bulletin to ALL Project Personnel)
Coordinator (20%)
(APE Schedule, Internal and External coordination of Health
Matters, Prepare Accidental Reports)
Clinician and Adviser (20%)
(Primary Prevention, Emergency Care, Health Assessment
and Treatment Services, Hazard Identification, Develop
Disaster Program and Discuss its Implementation Status
During Meetings)
Health Educator and Counselor (20%)
(Continuing Professional Development, Worker Education
and Training, Work Place Health Promotion)
Attitude Towards Work, Peers, and Supervisor (20%)

TOTAL POINTS EARNED RECOMMENDATION:

Tick the box besides rating:
For Continuation / Extension of Contractual Status
4.7 5.0 Excellent
For Termination of Employment
4.0 4.6 Very Good Reason: ____________________________________
3.0 3.9 Satisfactory Others: ____________________________________
2.0 2.9 Fair Starting Salary: _______________________
1.0 1.9 Poor
Existing Salary: _______________________
Last Salary Adjustment: ________________
Effective Date: ________________________
Date of Review:___________________ Employees Signature: ______________________________

Payroll Received Date: _______________ Received by: ________________________________________

3 copies of completed review Original to Human Resources Manager, Copy provided to employee and Department Head.