Date:

Performance Evaluation Dated:

1. I have discussed with my supervisor the evaluation of my past performance. I_____ agree _____ do not agree with______ all______ some of the conclusions reached, because:

2. I feel that my performance review fair and impartial, because:

3. If I could make changes or improvements in my work, or Company policies, I would suggest:

________________________ Date:

Employee

_________________________ Date:

Supervisor

_________________________ Date:

Evaluator