PERFORMANCE EVALUATION FORM

OFFICE/DIVISION

UNIT : Planning UnitPART I : PERFORMANCE (70%)Weight Unit of Measure / QUANTITY (QN) QUALITY (QL) TIME (T) RATINGAlloc. Work-KRA/Activity Indicator Targets Accomp. Targets Accomp. Targets Accomp. SUPERVISOR EMPLOYEE

(%) QN QL T APS EPS QN QL T APS20% 1. ME3-CHD Scorecard5% 1.1. Prepares Analysis of CHD Scorecard report QN-# of analysis 1 1 90% 97% 3 days/ 2 days/ 6 9 10 8.33 0.42 6 9 10 8.33

QL-% acceptability analysis analysisT- # of days / analysis

5% 1.2. Presents CHD Scorecard report with analysis QN-# of reports presented 1 2 90% 97% as scheduled as scheduled 10 9 - 9.50 0.48 10 9 - 9.50(thru various means, i.e., Mancom, RICT and PIRs) QL-% completeness / accuracy

T-as scheduled10% 1.3. Prepares /coordinates all the required validation QN-# of validation tools collected All All 90% 97% 1 week 2 days - 9 10 9.50 0.95 - 9 10 9.50

tools from concerned program managers QL-% completeness / accuracyT- # of days / tool

20% 2. ME3-LGU Scorecard10% 2.1Prepares Regional CY 2012 LGU Scorecard Report QN-# of LGU Scorecard report 1 reg'l. report 2 90% 98% 2 weeks 3 days 10 9 10 9.67 0.97 10 9 10 9.67

based on DILG-LGPMS Report by Province. QL-% acceptability (including LGU report in SLA)T- # of days / report

5% 2.2Prepares analysis of 2012 LGU SC Report.. QN-# of analysis 1 1 90% 97% 1 week 1 day 8 9 10 9.00 0.45 10 9 10 9.67QL-% acceptabilityT- # of days / analysis

5% 2.3 Disseminates / Provides feedback re: LGU SC QN-# of feesback provided ANA 2 90% 98% as scheduled as scheduled - 10 10.00 0.50 - 9 9.50 report (thru RICT, Health Summits, etc.) QL-% completeness / accuracy

T- as scheduled60% 3. Acts as Planning Assistant10% 3.1 Assists in the conduct of Agency Performance QN-# of APR Assisted 1 2 90% 98% July 23-25 July 23-25, Oct.16 10 10 10 10.00 1.00 10 10 10 9.67

Reviews (APRs) QL-% acceptabilityT-# of days/ review

10% 3.2 Assists in the preparation of APR quarterly reports QN-# of reports prepared 2 3 90% 98% 2nd week of July 2nd week of July 8 9 10 9.00 0.90 8 10 10 8.67QL-% acceptability & October 2nd week OctoberT-# of days/ report 4th week November

5% 3.3Assists in the preparation of BUB QN-# of reports prepared 2 2 90% 97% 4th week of July 4th week of July 6 9 - 7.50 0.38 6 8 - 7.00

For the rating period July to December , 2013

EMPLOYEE : MICHELLE G. OLIMBA : OFFICE OF THE REGIONAL DIRECTOR (STO)POSITION : Planning Assistant

Progress Report. QL-% acceptability & October & OctoberT-# of days/ report

5% 3.4 Assists in the monitoring of ETS. QN- # of plans monitored 6 6 90% 97% end of each month end of each month 6 9 - 7.50 0.38 6 9 - 7.50QL-% completeness / accuracyT-# of days/ report

10% 3.5 Prepares documents for budget hearing QN- # of documents prepared All All 90% 98% 3rd week Sept. 1st week August - 9 10 9.50 0.95 9 10 9.50(for 2014 Budget Proposal) QL-% completeness/acceptability

T-# of days/ document10% 3.6 Performs other function as may assigned by immediate QN- #of memo/comm. Prepared As they come 75 90% 99% July-December July-December - 10 - 10.00 1.00 - 10 - 10.00

supervisor & ARD (i.e., preparation of communications, QL-% acceptable feedbackmemoranda, etc.) T- as needed

10% 3.7 Attends to various seminars, meetings, workshops QN- #of trgs. Attended As they come 31 90% 98% July-December July-December - 9 - 9.00 0.90 - 9 - 9.00 (relative to ME3 & Planning) QL-% acceptable feedback

100% T- as scheduledTotal Equivalent Point Score (EPS) 9.26Multiply by Percentage Weight Allocation (70%)Weighted Average Score (WAS) 6.48

DISCUSS AND AGREE ON THE ABOVE TARGETS : Legend : PERC Action:QN - QuantityQL - QualityT - Time

12-Dec-13 APS - Ave. Point Score Rater Ratee Date EPS - Equivalent Point Score

27

DENICE U. PAGUIRIGAN, MPP. MICHELLE G. OLIMBA,RN.

PERFORMANCE EVALUATION FORM

RATINGEMPLOYEE

EPS

0.42

0.48

0.95

0.97

0.48

0.48

0.97

0.87

0.35

July to December , 2013

0.38

0.95

1.00

0.90

9.20

6.44

PART II. CRITICAL FACTORS (30%)

Behavioral Factors Self Rating (10%) Supervisor Rating (70%)Subordinate Rating (10%) Peer Rating (10%)

S1 S2 Total (Sub) P1 P2 P3 Total (Peers) 1. COURTESY 10 10 10 10 10 30.00 2. HUMAN RELATIONS 10 10 10 10 10 30.00 3. INTEGRITY 10 10 10 10 10 30.00 4. STRESS TOLERANCE 10 10 10 10 10 30.00 5. INITIATIVE / RESOURCEFULLNESS 10 10 10 10 10 30.00 6. COMPLIANCE TO OFFICE RULES AND REGULATIONS 10 10 10 10 10 30.00 7. PUNCTUALITY AND ATTENDANCE 8 8 10 10 10 30.00

0.000.00

Total Point Score 68 68 0 0 0 70 70 70 210.00 Divide by number of entries 7 7 7 7 7 21 Average Point Score (APS) 9.71 9.71 10.00 10.00 10.00 10.00COMMENTS AND RECOMMENDATIONS BY THE IMMEDIATE SUPERVISOR

Strong Point Weak Point Recommendations

SUMMARY OF RATINGSRATER Weighted Ave. Percentage Weight Allocation Total Weighted Weighted Ave. Percentage Weight Allocation Total Weighted Ave.

Score (WAS) With Without Ave.Score (TWAS) Score (WAS) With Without Score (TWAS)(Part I) Subordinate Subordinate (Part I) (Part II) Subordinate Subordinate (Part II)

Supervisor Rater 6.48 - 65% 4.21 9.71 - 70% 6.80 Self - Rater 6.44 - 35% 2.25 9.71 - 15% 1.46 Subordinate - - - - 0.00 - - - Peer Rater 10.00 - 15% 1.50 Total Weighted Average Score (TWAS) 6.47 9.75

Total Weighted Average Score (TWAS) (Part I) 6.47 Total Weighted Average Score (TWAS) x 30% (Part II) 9.75 X 0.30 = 2.93 Total Overall Score (TWAS Part I + TWAS Part II) 9.39 Add : Intervening Task ( If any ) Final Numerical Rating Adjectival Rating Very Satisfactory

DENICE U. PAGUIRIGAN, MPP. MICHELLE G. OLIMBA, R.N. CORAZON I. FLORES, MD.,MPH, CESE Dec. 12, 2013Planning Officer III Planning Assistant OIC- Director III

Rater Ratee Date

PERC Action (Please encircle) Approval / Disapproval

PERC Chairman

8. LEADERSHIP ( for supervisors only ) 9. JUDGEMENT / DECISION MAKING ( for supervisors only )

Confirm by Next Higher

Supervisor

PERFORMANCE EVALUATION FORM

LEAH M. SUBELDIA PROVINCE: QUEZON

POSITION: NDP MUNICIPALITY: TIAONGPART I : PERFORMANCE (70%)

Weight Unit of Measure / QUANTITY (QN) QUALITY (QL) TIME (T) RATINGAlloc. Work-KRA/Activity Indicator Targets Accomp. Targets Accomp. Targets Accomp. SUPERVISOR EMPLOYEE

(%) QN QL T APS EPS QN QL T

10% A.1 Attendance to pre-natal visits QN-# of pre-natal visits attended 71 95 96% 97% 6 6 10 10 6 8.67 0.87 10 10 6QL-% accuracy (effectivity,safeness)T- w/in 6 months

10% A. 2 Attendance to post-natal care QN-# of post-natal visits attended 17 25 96% 96% 6 6 9 10 6 8.33 0.83 8 10 6QL-% accuracy (effectivity,safeness)T- w/in 6 months

10% A. 3 Participate in EPI QN-# of children vaccinated (0-11 months old)56 75 91% 95% 6 6 10 9 6 8.33 0.83 10 9 6

QL-% of effectivity

T- w/in 6 months

10%QN-# of Health Education/Advocacy Conducted 15 20 91% 95% 6 6 10 9 6 8.33 0.8 10 9 6

QL-% effectivityT- w/in 6 months

10% A. 5 Number of presumptive TB cases identified QN-# of presumptiveTB cases identified 13 20 91% 95% 6 6 9 9 6 8 0.8 8 9 6QL-% effectivenessT- w/in 6 months

For the rating period JULY to DECEMBER, 2015

EMPLOYEE: ___________________________________

A. Assists in the implementation of various health programs of the Local Gov't Unit in accordance with the program goals and objectives of the DOH and the health sector

A. 4 Conduct Health Program Education / Advocacy (Breastfeeding, Family Planning, Healthy Lifestyle, STI-HIV/AIDS)

5% A. 6 Number of 25 years old and above screened for Non Com QL-% accuracyDiseases (HPN) T- w/in 6 months

5% B1. Records and reports of services per program Qty: # of records and reports of services per program 6 9 91% 95% 6 6 10 9 6 8.33 0.42 10 9 6Qlty: Completeness of dataTime: w/in 6 months

5% B2. Performs monthly analysis of FHSIS submitted reports Qty: No. of health programs reports analyzed 6 9 96% 96% 6 6 10 10 6 8.67 0.43 10 10 6Qlty: Acceptability and completenessTime: within 6 months

2% B3. Referrals made for further management. Qty: No. of referrals made 13 20 96% 97% 6 6 9 10 6 8.33 0.17 9 10 6Qlty: CompletenessTime: w/in 6 months

2% E.2 Monitors and follow up the outcome of referrals Qty: No. of referrals monitored and followed up 10 15 96% 96% 6 6 9 10 6 8.33 0.17 9 10 6Qlty: Accuracy Time: w/in 6 months

4% Qty: No. of assistance provided10 15 91% 95% 6 6 9 9 6 8 0.32 9 9 6

Qlty: % effectiveness / acceptabilityTime: w/in 6 months

10% E.1 Track and follow up EPI, FP and MNCHN defaulters. Qty: No. of defaulter tracing and follow ups done 19 25 91% 95% 6 6 10 9 6 8.33 0.8 10 9 6Qlty: EffectivenessTime: w/in 6 months

G. Assists in supply management

B. Recording and reporting (FHSIS and other health programs)

C. Assists/Reports in disease surveillance/ emergencies and disasters/unusual events/notifiable deseases(zero reporting)

5%Qty: No. of times inventory done

6 9 96% 97% 6 6 10 10 6 8.67 0.43 10 10 6

Qlty: % effectiveness

Time: w/in 6 months

5% Qty: No. of submitted reports

6 6 96% 98% 6 6 6 6 6 6 0.3 6 6 6

Qlty: % Completeness and acceptabilityTime: w/in 6 months

7% Qty: No. of activity conducted11 15 91% 95% 6 6 10 9 6 8.33 0.58 10 9 6

Qlty: % effectiveness/acceptabilityTime: w/in 6 months

105%

Total Equivalent Point Score (EPS) 8.20Multiply by Percentage Weight Allocation (70%) x70%Weighted Average Score (WAS) 5.74

DISCUSS AND AGREE ON THE ABOVE TARGETS : Legend : PERC Action:QN - QuantityQL - QualityT - Time

MARIA VICTORIA M. PALICPIC, RN LEAH M. SUBELDIA, RN 1-Jul-15 APS - Ave. Point Score Rater Ratee Date EPS - Equivalent Point Score

G.1 Conduct inventory of FP commodities, drugs, vaccines and other resources

F. Timely submission of monthly accomplishment reports, DTR and other reports as required to include incidental reports to the RO IV-A

I. Perform other related functions in accordance with NDP AO, SBI, Kilatis Kutis, provision of technical assistance to CHT members and partners etc.

PERFORMANCE EVALUATION FORM

RATINGEMPLOYEE

APS EPS

8.67 0.87

8 0.8

8.33 0.83

8.33 0.8

7.67 0.77

JULY to DECEMBER, 2015

8 0.4

8.67 0.43

8.33 0.17

8.33 0.17

8 0.32

8.33 0.8

8.67 0.43

6 0.3

8.33 0.58

8.12x70%

5.68

PART II. CRITICAL FACTORS (30%)

Behavioral Factors Self Rating (10%) Supervisor Rating (70%) Subordinate Rating (10%) Peer Rating (10%)S1 S2 Total (Sub) P1 P2 P3 Total (Peers) 1. COURTESY 10 8 10 10 10 30.00 2. HUMAN RELATIONS 10 6 10 10 10 30.00 3. INTEGRITY 10 6 10 10 10 30.00 4. STRESS TOLERANCE 10 6 10 10 10 30.00 5. INITIATIVE / RESOURCEFULLNESS 10 6 10 10 10 30.00 6. COMPLIANCE TO OFFICE RULES AND REGULATIONS 10 6 10 10 10 30.00 7. PUNCTUALITY AND ATTENDANCE 10 6 10 10 10 30.00

Total Point Score 70 44 70 70 70 210.00 Divide by number of entries 7 7 7 7 7 21 Average Point Score (APS) 10.00 6.29 10.00 10.00 10.00 10.00COMMENTS AND RECOMMENDATIONS BY THE IMMEDIATE SUPERVISOR

Strong Point Weak Point Recommendations

SUMMARY OF RATINGSRATER Weighted Ave. Percentage Weight Allocation Total Weighted Weighted Ave. Percentage Weight Allocation Total Weighted Ave.

Score (WAS) With Without Ave.Score (TWAS) Score (WAS) With Without Score (TWAS)(Part I) Subordinate Subordinate (Part I) (Part II) Subordinate Subordinate (Part II)

Supervisor Rater 6.01 - 65% 3.91 6.29 - 70% 4.40 Self - Rater 6.01 - 35% 2.10 10.00 - 15% 1.50 Subordinate - - - - - - Peer Rater 10.00 - 15% 1.50 Total Weighted Average Score (TWAS) 6.01 7.40

Total Weighted Average Score (TWAS) (Part I) 6.01 Total Weighted Average Score (TWAS) x 30% (Part II) 7.4X30% = 2.22 Total Overall Score (TWAS Part I + TWAS Part II) 6.01 + 2.22 Add : Intervening Task ( If any ) Final Numerical Rating 8.23 Adjectival Rating Very Satisfactory

MARIA VICTORIA M. PALICPIC SARAH MAE D. TECSONRater Ratee Date

PERC Action (Please encircle) Approval / Disapproval

PERC Chairman

8. LEADERSHIP ( for supervisors only ) 9. JUDGEMENT / DECISION MAKING ( for supervisors only )

Confirm by Next Higher

Supervisor

Part 1 (June-December 2013) (2)Part 2 (June-December 2013 (2)Part 1Part 2