Employee Information

Employee	Hire Date
Current Title	Current Salary
Performance Review Period	2019	Current Bonus

Please complete and return this self-evaluation to your supervisor by January 15th.
Your thorough and timely participation in the appraisal process will help facilitate a fair and comprehensive review of your progress and accomplishments since the last performance review. If you have been employed by the company less than a year, substitute references to "since the last performance appraisal/review" with "since you were hired" and answer the questions accordingly.

List your most significant accomplishments or contributions since last year. How do these achievements align with the goals/objectives you and/or your manager may have discussed or established in your last review?

What changes or challenges in duties or priorities did you face during the review period and how did you handle them?

What are your strengths (the things you do well) and how do you put them to use in your position?

Describe areas you feel require improvement in terms of your professional capabilities. List the steps you plan to take and/or the resources you need to accomplish this.

Identify one or two career goals for the coming year and indicate how you plan to accomplish them.

How can your supervisor help you to work more effectively and support your goals?

What feedback or suggestions do you have to improve your immediate department or the work environment of TPA, overall?

Name any other peer or management personnel, besides your current supervisor, that you feel should provide input toward your performance appraisal.

Compensation Recommendation (to be completed by manager)

COLA percentage
Other
Promotion Recommendation (only if applicable)	New Title	New Compensation	New Bonus Amt

Verification of Review

By signing this form, you confirm that you have discussed this review in detail with your supervisor. Signing this form does not necessarily indicate that you agree with this evaluation.
Employee Signature	Date
Supervisor/Manager Signature	Date

Executive Committee & CFO approvals

EC Member Signature	Date
CFO Signature	Date