Summary and Signature Form

Performance Feedback

Summary and Signature Form

For Department Head/Section Head or Designate and GFT/Nil Salaried Faculty Members

Name Faculty Member: / Date:
Name Reviewer: / Department:

This form is to be filled out by the Department Head/Section Head or their designate and the Faculty Member. Upon submission of the Performance Feedback Form for GFT Faculty Members, the Reviewer shall schedule a Performance Review meeting and prepare their feedback (in conjunction with the Program Clinical Lead, if biennial review of clinical activities is applicable). The face to face meeting results in, or is followed by filling out this Summary and Signature Form. The form includes the feedback from the Department Head/Section Head or designate, the Faculty Members’ response, and signatures.

1. Feedback from the Department Head/Section Head or Designate

1. Feedback on Teaching Activities

Provide comments on accomplishments, strengths, opportunities and if the goals established in the previous performance feedback process were accomplished. Provide detailed comments and specific expectations when improvements are needed.

1. Feedback on Scholarly Activity and/or Scholarship

Provide comments on accomplishments, strengths, opportunities and if the goals established in the previous performance feedback process were accomplished. Provide detailed comments and specific expectations when improvements are needed.

1. Feedback on Administration/Service Activities

Provide comments on accomplishments, strengths, opportunities and if the goals established in the previous performance feedback process were accomplished. Provide detailed comments and specific expectations when improvements are needed.

1. Biennial feedback on Clinical Activities by Department Head/Section Head, Clinical Program Lead or designate

Biennially and if applicable, provide comments on accomplishments, strengths, weaknesses and if the goals established in the previous performance feedback process were accomplished. Provide detailed comments and specific expectations when improvements are needed.

Follow up Action Required?

No

Yes.

Please describe the specific follow-up action requested:

1. Department Head/Section Head or Designate agreement with goals

Please indicate whether you have reviewed and support the proposed goals

I have read and support the goals purposed for the upcoming years. The goals are aligned with the faculty members’ Letter of Offer and are on target with respect to the career goals of this member.

I have read and do not support the goals purposed for the upcoming years. The goals are not aligned with the faculty members’ Letter of Offer (if applicable) and/or do not adequately support the career goals of this member.

Comments from the Department Head/Section Head or Designate:

1. Comments and Response from GFT/Nil Salaried Faculty Members on Part A and B

If you wish, you may provide a response to or comment on the feedback provided by the Department Head/Section Head or Designate. To guarantee an ethically sound process, it is advised to add this response in handwriting on the printed document.

Signature Faculty Member for response: / Date:

Signatures

Name and signature of individual who provided performance feedback

______

Printed Name, Title Date

______

Signature

Performance Review Form and Summary Form reviewed by Department Head

______

Signature of Department HeadDate

Performance Review Form and Summary Form reviewed by Faculty Member

______

Signature of Faculty MemberDate

1

Performance Feedback Summary Form for Reviewers and GFT/Nil Salaried Faculty Members | March 2014

Appendix I to the FOM Career Development and Performance Feedback Policy