The 3-2-1
Performance Check-In Form
Review Period: From To
EMPLOYEE
Employee Name: Hazem Alnusairat Title: Medical Doctor Date: 10/08/2019
Write in your goals established at the beginning of or during the review period. Comment about accomplishments
or progress made for each goal and challenges you faced.
Think about your achievements and identify 2 areas of strength that you have observed in yourself. An example
of a strength may be a task or process that comes easily to you, and something that excites/motivates you.
Identify 1 growth area you wish to focus on in the next 3-6 months. This may be a task or process you find
particularly challenging, or something you need to learn more about in order to excel in your role.
OPTIONAL: Select the most appropriate rating for your performance over the year from the dropdown list.
Email this form to your manager.
Goal 1 and comments:
Goal: Enhance the quality of health education services provided in the clinic by creating structured health education package
for providing health messages for clinic staff.
Comments/accomplishments/challenges: The health messages were successfully done at the time and it was useful, no
challenges stop the education in general.
Complete On track Delayed Not started No longer relevant
Goal 2 and comments:
Goal: Enhance and monitor the clinic infection control procedures and practices among the staff to avoid the spread of
infectious diseases.
Comments/accomplishments/challenges: It’s going well, and this year I had training about infectious disease and Infection
Control, which is increased in knowledge and let me work with right way. Finally, I could win on the challenges which faced me.
Complete On track Delayed Not started No longer relevant
Goal 3 and comments:
Goal: Improve self-development both in management and technical health areas these may include communication skills
training or NCDs training.
Comments/accomplishments/challenges: I have been improved self in communication skills by direct connection with patients
from all ages and genders, the goal was changed about NCDs training to infection control training, after that training I feel my
self more confident and able to improve work environment, and infection control.
Complete On track Delayed Not started No longer relevant
(If applicable) Goal 4 and comments:
Goal
Comments/accomplishments/challenges:
Complete On track Delayed Not started No longer relevant
(If applicable) Goal 5 and comments:
Goal:
Comments/accomplishments/challenges:
Complete On track Delayed Not started No longer relevant
What are two of your strengths? An example of a strength may be a task or process that comes easily to you, and
something that excites/motivates you.
Strength 1:
Listening to patients and analysis their personality with introduce psychological support for them.
Strength 2:
The continuous working for several hours without interruption and in same quality.
What is one growth area you wish to focus on in the next 3-6 months? This may be a task or process you find
particularly challenging, or something you need to learn more about in order to excel in your role
I wish to travel out of Jordan to work in another IRC’s clinic to practice what I can do from good job.
OPTIONAL: Your self-rating based on your performance throughout review period:
Successfully Meets Expectations
Click here for tips on selecting a rating.
Outstanding Exceeds Expectations Successfully Meets Mostly Meets Does Not Meet
Expectations Expectations Expectations
Exceptionally high quality Consistently exceeded Consistently met Met expectations of some Generally failed to meet
of work performed in all expectations in all key expectations in all key key areas, generally expectations. Required
key areas, significantly areas and the quality of areas, overall quality very performed at a minimum frequent, close
increased effectiveness of work overall was good, consistent with all level. Improvement supervision, redoing of
department/unit excellent. core requirements needed to meet work, significant
expectations. improvement needed.
MANAGER
Manager Name: Click here to enter text. Title: Click here to enter text. Date: Click here to enter text.
Review your employee’s goals established at the beginning and/or throughout the review period.
Consider feedback you have received from your employee’s reports or peers.
Comment about your employee’s accomplishments or progress made for each goal.
Comment on what you see as your employee’s strengths and one area for improvement.
Select an overall rating for your employee’s performance over the past year/review period.
Hold a discussion with your employee to review progress towards goals, discuss strengths and areas of
development.
You and your employee sign the form. Submit a copy of the form to HR.
Comment on employee’s accomplishments, challenges, strengths, area of development and overall way of working:
Year-end review discussion held on Click here to enter a date.
Final rating based on the employee’s performance throughout review period:
Choose an item.
Click here for tips on selecting a rating.
Outstanding Exceeds Expectations Successfully Meets Mostly Meets Does Not Meet
Expectations Expectations Expectations
Exceptionally high quality Consistently exceeded Consistently met Met expectations of some Generally failed to meet
of work performed in all expectations in all key expectations in all key key areas, generally expectations. Required
key areas, significantly areas and the quality of areas, overall quality very performed at a minimum frequent, close
increased effectiveness of work overall was good, consistent with all level. Improvement supervision, redoing of
department/unit excellent. core requirements needed to meet work, significant
expectations. improvement needed.
Employee Signature*: Manager Signature:
Date: 10/08/2019 Date:
* Signature indicates that this review has been provided to the employee and the employee has read and discussed it. It does not indicate
agreement
with all content within the review.
For HRP use only